Advances in traction methods for endoscopic submucosal dissection: What is the best traction method and traction direction?

Abstract

Endoscopic submucosal dissection (ESD) has been developed as a treatment for superficial gastrointestinal neoplasms, which can achieve en bloc resection regardless of the lesion size. However, ESD is technically difficult because endoscopists cannot bring their hand into the gastrointestinal tract, unlike surgeons in regular surgery. It is difficult to obtain sufficient tension in the dissection plane and a good field of vision. Therefore, ESD is associated with a long procedure time and a high risk of adverse events in comparison with endoscopic mucosal resection. Traction methods have been developed to provide sufficient tension for the dissection plane and a good field of vision during the ESD procedure. However, traction direction is limited in most traction methods, resulting in insufficient effect in some cases. Although traction direction is considered important, there have been few investigations of its effect. In the first half of this review, important traction methods are discussed, including traction direction. In second half, appropriate traction methods for each organ are considered. Other important considerations for traction method, such as ability to adjust traction strength, interference between traction device and endoscope, and the need for specialized devices are also discussed.

Keywords: Endoscopic submucosal dissection; Traction method; Countertraction; Traction direction; Vertical traction

Core Tip: Endoscopic submucosal dissection is associated with a long procedure time and adverse events (e.g., perforation) due to technical difficulty—the absence of tension for the dissection plane and poor field of vision. Traction methods allow efficient dissection and a good field of vision. Although many traction methods have been developed, traction direction is limited in most. Each traction method has advantages and disadvantages. It is important to select an appropriate traction method to obtain proper traction direction, depending on lesion location. We discuss the characteristics of different traction methods and their effects depending on traction direction.