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World J Gastrointest Endosc. Apr 16, 2023; 15(4): 265-272
Published online Apr 16, 2023. doi: 10.4253/wjge.v15.i4.265
Device-assisted traction methods in colorectal endoscopic submucosal dissection and options for difficult cases
Mitsuru Nagata
Mitsuru Nagata, Department of Endoscopy, Shonan Fujisawa Tokushukai Hospital, Fujisawa 251-0041, Kanagawa, Japan
Author contributions: Nagata M has been associated with the conception, drafting of the article, and final approval of the article.
Conflict-of-interest statement: No financial relationships with a commercial entity producing health-care-related products and/or services relevant to this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Mitsuru Nagata, MD, Chief Doctor, Department of Endoscopy, Shonan Fujisawa Tokushukai Hospital, 1-5-1, Tsujidoukandai, Fujisawa 251-0041, Kanagawa, Japan. mitsuru10jp@yahoo.co.jp
Received: December 22, 2022
Peer-review started: December 22, 2022
First decision: February 15, 2023
Revised: February 25, 2023
Accepted: March 30, 2023
Article in press: March 30, 2023
Published online: April 16, 2023
Processing time: 113 Days and 3.3 Hours
Abstract

Endoscopic submucosal dissection (ESD) procedure has a longer procedure time and higher perforation rate than endoscopic mucosal resection owing to technical complications, including a poor field of vision and inadequate tension for the submucosal dissection plane. Various traction devices were developed to secure the visual field and provide adequate tension for the dissection plane. Two randomized controlled trials demonstrated that traction devices reduce colorectal ESD procedure time compared with conventional ESD (C-ESD), but they had limitations, including a single-center fashion. The CONNECT-C trial was the first multicenter randomized controlled trial comparing the C-ESD and traction device-assisted ESD (T-ESD) for colorectal tumors. In the T-ESD, one of the device-assisted traction methods (S–O clip, clip-with-line, and clip pulley) was chosen according to the operator’s discretion. The median ESD procedure time (primary endpoint) was not significantly different between C-ESD and T-ESD. For lesions ≥ 30 mm in diameter or in cases treated by nonexpert operators, the median ESD procedure time tended to be shorter in T-ESD than in C-ESD. Although T-ESD did not reduce ESD procedure time, the CONNECT-C trial results suggest that T-ESD is effective for larger lesions and nonexpert operators in colorectal ESD. Compared with esophageal and gastric ESD, colorectal ESD has some difficulties, including poor endoscope maneuverability, which may be associated with prolonged ESD procedure time. T-ESD may not effectively improve these issues, but a balloon-assisted endoscope and underwater ESD may be promising options and these methods can be combined with T-ESD.

Keywords: Endoscopic submucosal dissection; Traction; Traction direction; Balloon-assisted endoscope; Underwater endoscopic submucosal dissection

Core Tip: Various traction devices were developed to overcome the challenges faced in endoscopic submucosal dissection (ESD). A multicenter randomized controlled trial in Japan compared the conventional ESD and traction device-assisted ESD (T-ESD) for colorectal tumors. Although T-ESD did not reduce ESD procedure time, the results of this study suggest that T-ESD is effective for larger lesions and nonexpert operators. A balloon-assisted endoscope and underwater ESD may be promising options and these methods can be combined with T-ESD.