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Background Although several methods to create an effective counter traction for safer endoscopic submucosal dissection (ESD) have been reported, these methods do not overcome problems regarding delivery and ease of use. This randomized prospective study assessed the usefulness of ring-shaped thread counter traction, which not only allowed the safer colorectal ESD but also the easiest and lower cost counter traction without any special devices. Methods Forty-five patients diagnosed with colorectal lateral spreading tumors over 20 mm were allocated to the conventional ESD group (CE) ( n  = 22) and the ring-shaped thread counter traction ESD group (RE) ( n  = 21). The ring-shaped thread was hooked and lifted up to the contralateral mucosa with a hemoclip. The primary outcome was the dissected area per minute during ESD (cm 2 /min) (UMIN000020160). Results There were significant differences in the dissection time (min), with 130.0 (56.0–240.0) versus 80 (35.0–130.0) min for the CE and RE groups, respectively ( P  = 0.001). For the dissected areas per minute (cm 2 /min), there was a significant difference, with 0.125 (0.1–0.18) versus 0.235 (0.16–0.36) min ( P  = 0.003) for the CE and RE groups, respectively. There were 1 cases of perforation during ESD in the CE compared to 0 for the RE, and this was no significantly different ( P  = 0.31). The procedure time of producing and setting the ring-shaped thread counter traction was approximately 1.80 (0.80–3.30) min only. Conclusions The ring-shaped thread counter traction is simple, effective, lower cost and does not require special devices to obtain repeated counter traction.

ObjectiveThis study aims to investigate the efficacy and safety of snare traction-assisted endoscopic submucosal dissection (ESD) for the management of circumferential superficial esophageal cancer.MethodsA total of 68 patients who underwent ESD for circumferential superficial esophageal cancer were included in this study. All the patients were divided into two groups based on whether the snare traction was used or not; the snare traction group (S-ESD, group n = 35) and the control group (C-ESD, group n = 33).ResultsThere was no significant difference in the size of the resected area between the groups [21.98 (18.30, 27.00) cm2 vs 24.00 (15.28, 30.72) cm2, P = 0.976]. The snare traction group had a shorter dissection time [92.00 (74.00, 121.00) min vs 110.00 (92.50, 137.00) min, P = 0.017] and a faster resection speed [0.28 ± 0.13 cm2/min vs 0.22 ± 0.11cm2/min, P = 0.040] compared to the control group. There were no statistically significant differences between the two groups in terms of hospital stay, cost, en bloc resection rate, R0 resection rate, curative resection rate, bleeding rate, perforation rate, stricture rate, and recurrence rate (P > 0.05).ConclusionSnare traction-assisted ESD is a safe and efficient approach for the treatment of circumferential superficial esophageal cancer. Its advantages includes shorter procedure so the anesthesia requirement, clear operative filed view, improved mucosal dissection efficiency, simple, and easily accessible equipment.

Endoscopic submucosal dissection (ESD) is a standard treatment for rectal laterally spreading tumors (LSTs). This study aims to compare the efficacy and safety of the Injection Mucosa Knife (IMK) technique versus the conventional Dual Knife (DK) technique in ESD for rectal LSTs. A total of 229 patients with rectal LSTs were enrolled from four hospitals between June 2020 and June 2025 and were divided into two groups: the IMK group ( n  = 108) and the DK group ( n  = 121). The primary outcome measures included total procedure time, mucosal dissection time, and submucosal dissection rate, while the secondary outcomes encompassed intraoperative and postoperative complications as well as the R0 resection rate. Additionally, the efficacy and safety of the two groups were compared based on tumor size and endoscopic morphology. The IMK group demonstrated significantly shorter total procedure time (median 50 vs. 65 min, P  < 0.001) and mucosal dissection time (median 40 vs. 56 min, P  < 0.001), along with a higher submucosal dissection rate (median 0.12 vs. 0.08 cm²/min, P  < 0.001). There were no significant differences in intraoperative perforation, severe hemorrhage, R0 resection, postoperative bleeding, fever, or pathology between the two groups ( P  > 0.05). Subgroup analyses based on tumor size (2.5 cm and ≥ 2.5 cm) and morphology (LST-G and LST-NG) consistently showed superior efficiency of the IMK technique without compromising safety. The IMK technique significantly improves the efficiency of ESD for rectal LSTs by reducing operative time and enhancing dissection rates, while maintaining comparable safety and outcomes to the conventional DK technique. IMK represents a promising advancement in ESD for rectal lesions.

Purpose For the treatment of advanced colorectal neoplasms, colon endoscopic submucosal dissection (ESD) is a crucial technique, although it is time-consuming. The purpose of this study was to evaluate the efficacy of a recently developed one-step knife (OSK) in colon ESD and compare its performance with that of a conventional knife (CK). Methods Between July 2020 and November 2021, patients scheduled to undergo colorectal ESD were randomly assigned to either the OSK group or the CK group. The primary outcome was the total submucosal injection time. Additionally, total procedure time, treatment outcomes, adverse events, and operator convenience were analyzed. Results Data from 53 patients (28 in the OSK group and 25 in the CK group) were analyzed. The mean total injection time was lower in the OSK group than in the CK group (186 s [IQR, 116.8–249.5] vs. 265 s [IQR, 130.5–553.0]), but the difference was not statistically significant ( P  = 0.082). The total procedure time tended to be shorter in the OSK group than in the CK group (15.5 min [IQR, 11.3–22.8] vs. 20 min [IQR, 13.5–42.5], P  = 0.110). Resection rates and adverse events did not differ between the two groups. A greater proportion of endoscopists expressed high satisfaction with the OSK, particularly regarding submucosal injection. Conclusion Compared to the CK, OSK use led to shorter injection and procedure times, though not statistically significant. The use of this newly developed endoscopic knife can potentially enhance the effectiveness and efficiency of colorectal ESD (Clinical Research Information Service: KCT0005123).

Purpose Adequate oxygenation and airway management during deep sedation can be challenging. We investigated the effect of high-flow nasal cannula (group HF) and conventional nasal cannula (group CO) during sedation for endoscopic submucosal dissection (ESD). Methods Patients undergoing ESD with deep sedation were enrolled. The primary outcome was difference in lowest oxygen saturation (SpO 2 ) between the groups. Incidence of hypoxia (SpO 2  < 90%), patients with SpO 2  < 95%, hypercapnia, and airway interventions; operator satisfaction; and adverse events were recorded. Results Thirty-two patients in each group completed the study. The mean of minimum SpO 2 values was significantly higher in group HF than in group CO (96.8% ± 4.2% vs. 93.3% ± 5.3%, p  = 0.005). The incidence of hypoxia was comparable between the groups (4 [12.5%] vs. 6 [18.8%], p  = 0.491); however, patients with SpO 2  < 95% were significantly less in group HF (5 [15.6%] vs. 18 [56.3%], p  = 0.003). Incidence of hypercapnia was higher in group HF than in group CO (14 [46.7%] vs. 5 [16.7%], p  = 0.013). Airway rescue interventions were significantly less common in group HF. Satisfaction of operators and post-procedural complications were comparable between the two groups. In multivariable analysis, group CO and higher body mass index were risk factors for airway managements (odds ratio [95% confidence interval]: 6.204 [1.784–21.575], p  = 0.004; 1.337 [1.043–1.715], p  = 0.022, respectively). Conclusions Compared to conventional nasal cannula, high-flow nasal cannula maintained higher minimum SpO 2 value during deep sedation with propofol–remifentanil for ESD. Trial registration Clinical Trial Registry of the Republic of Korea (KCT0006618, https://cris.nih.go.kr ; registered September 29, 2021; principal investigator: Ji Won Choi).

Introduction ESD is the treatment of choice for superficial neoplasms of the oesophagus; ESD is oncologically efficient and associated with less morbidity than the surgical alternative. ESD requires a high level of skill, being both technically challenging and time consuming. Therefore, ESD is often reserved for experts. A combination of a tunnel technique with clip-line traction may enable optimisation of oesophageal ESD. Patients and methods From January 2015 to December 2016, we performed a prospective two-centre case study of consecutive “tunnel + clip” oesophageal ESD. Four young operators (each of whom had performed fewer than 50 ESDs and fewer than five oesophageal ESDs) treated patients requiring ESD using the tunnel + clip method. This involves generation of a classic tunnel beneath the lesion, with constant traction being applied by a clip with a line placed at the oral side of the tunnel. Results Sixty-two lesions (25 SCCs and 34 ADK/HGDs complicating Barrett’s oesophagus) were consecutively resected. The en bloc, R0, and curative resection rates were 100% (62/62), 88.7% (55/62), and 74.2% (46/62), respectively. No perforation was noted. The mean ESD velocity was 24.5 mm 2 /min for lesions of mean length 59.6 mm. The tunnel + clip approach greatly aided the procedure. No pathological damage caused by clipping was evident. Conclusion Use of the tunnel + clip strategy to treat oesophageal ESD is effective and safe, even when performed by physicians with little prior experience. It is thus possible to standardise ESD of superficial oesophageal neoplasms and increase the velocity of dissection. Our procedure will encourage the use of oesophageal ESD in Western countries.

Background Most mucosal defects that occur with endoscopic submucosal dissection (ESD) can be closed completely using endoscopic clips. However, benefits of such closure in wound healing are unknown. A randomized controlled study evaluated the efficacy of closure with clips compared with no closure. Method Twenty-eight patients who had undergone ESD were randomly divided into two groups: closure ( n  = 14) and non-closure groups ( n  = 14). In the closure group, the mucosal defect resulting from ESD was closed using endoscopic clips. Four weeks after ESD, defects in both groups were observed by colonoscopy. Efficacy was based on change in the area of the defect, percentage of complete healing in each group, and complications. Result Data were analyzed for 26 of the 28 patients (13, closure group; 13, non-closure group). All tumors were resected en bloc by ESD without bleeding or perforation. In the closure group, the area of the defect just after ESD was 677 ± 306 mm 2 (mean ± SD) as determined by the size of the removed lesion and had decreased to 2.17 ± 4.51 mm 2 at 4 weeks after ESD (reduction, 99.7 %), but in the non-closure group that area was 790 ± 221 mm 2 and had decreased to 27.42 ± 25.72 mm 2 at 4 weeks post-ESD (reduction, 96.2 %). The reduction rate was significantly higher in the closure than in the non-closure group (99.7 vs. 96.2 %, p  = 0.010). Complete healing was 69.2 % in the closure group vs. 7.7 % in the non-closure group ( p  = 0.005). Multivariate analysis showed that closure of the mucosal defect (OR 24.029, 95 % CI 2.09–276.15, p  = 0.011) was an independent factor associated with complete healing at 4 weeks after ESD. Delayed perforation or post-ESD bleeding was not observed in any participant. Conclusion Use of endoscopic clips for closure of defects after ESD is safe and efficacious in accelerating wound healing. Trial registration UMIN-CTR UMIN000009112

Background and aims Good use of the submucosal space is key during endoscopic submucosal dissection (ESD). High-pressure injection of a long-lasting viscous solution using the HybridKnife water-jet system has been demonstrated to be feasible. We compared jet injection of glycerol and normal saline during pig gastric ESD and assessed its feasibility and efficiency during human ESD. Materials and methods A blinded randomised controlled study of ESD with the HybridKnife injecting either a glycerol mixture or normal saline and a prospective human case series were performed. Twenty gastric pig dissections (10/group) and 38 human ESDs along the gastrointestinal tract were performed. Dissection speed, specimen size, procedure duration, rates of en bloc and R0 resection, and rates of bleeding and perforation were prospectively recorded. An evaluation of operator comfort and perceived safety (dissection score) was performed using a visual analogue scale with zero being the worst score and ten the best. Results Dissection was significantly more rapid (1.38-fold) with glycerol injection than with normal saline injection (28.94 vs. 20.91 mm 2 /min; p  = 0.037). The dissection score was significantly higher in the glycerol group than in the normal saline group (7.3 vs. 4.7; p  = 0.0064). No differences were observed in the rates of en bloc resection, bleeding, or perforation. The 38 human cases along the gastrointestinal tract revealed good results ( en bloc resection rate = 100 %, R0 resection rate = 90 %) without any complications. Conclusion High-pressure jet injection of glycerol with the HybridKnife for ESD increased the speed and operator comfort of the procedure compared with the use of normal saline, and the procedure was safe and efficient for human ESD. The advantages of using a combination of the HybridKnife system and a viscous glycerol solution will help to spread the use of the ESD technique, particularly in non-Asian countries.

BackgroundMultiband mucosectomy (MBM) is the preferred technique for piecemeal resection of early neoplastic lesions in Barrett’s esophagus (BE). The currently most widely used device for MBM is the Duette device. Recently, the Captivator EMR device has come available which might have practical advantages over the Duette device.MethodsPhase I was a randomized pre-esophagectomy trial with a non-inferiority design aiming to compare EMR specimens obtained with the Captivator and the Duette device. Primary outcome: max diameter of the EMR specimens, secondary outcomes: min diameter, max thickness of the EMR specimens and resected submucosal stroma. Phase II were clinical pilot cases aiming to evaluate the feasibility of EMR using the Captivator device. Primary outcome was the successful EMR rate and secondary outcomes included procedure time and adverse events.ResultsPhase I: 24 EMR specimens (12 pairs) were obtained from six patients. The median max diameter of EMR specimens obtained with the Captivator device was 16 mm [IQR 12–21] versus 18 mm [IQR 13–23] for the Duette device. Non-inferiority of the max diameter of the Captivator specimens could not be demonstrated (median difference 1 mm, 95% CI − 3.26 to + 5.26). However, when using paired analysis, no significant difference was found (p 0.573). In addition, no statistically significant differences were found in the min diameter, max thickness of EMR specimens, and max thickness of resected submucosal stroma. Phase II: 5 BE patients with early neoplastic lesions were included. Successful EMR was achieved in 100%. Median procedure time was 33 min (IQR 25–39). One patient developed transient dysphagia, without signs of stenosis on endoscopy.ConclusionsEMR of early Barrett’s neoplasia using the Captivator device is comparable to Duette EMR when looking at size of resected specimens. In the first patients, EMR using the Captivator was feasible, resulting in successful resection without acute adverse events.

INTRODUCTION:Precutting endoscopic mucosal resection (EMR-P) is a modified EMR method for the resection of large nonpedunculated colorectal polyps. In EMR-P, a mucosal incision is made using a snare-tip or endoscopic submucosal dissection (ESD) knife. However, there are concerns that the snare-tip may have a lower procedural success rate than the ESD knife. We aimed to assess the efficacy and safety of EMR-P using a snare-tip compared with that using an ESD knife for large nonpedunculated colorectal polyps.METHODS:Large nonpedunculated colorectal polyps (15–25 mm) were randomly allocated to either the snare-tip or ESD knife EMR-P group. The primary outcome was the en bloc resection rate.RESULTS:Resection was performed using a snare-tip or ESD knife in 53 patients each. In the intention-to-treat population, the en bloc resection rates for the snare-tip and ESD knife EMR-P groups were not significantly different (98.1% vs 98.1%, P = 1.000). The R0 resection rate in the snare-tip group was not significantly different from that in the ESD knife group (88.7% vs 92.5%, P = 0.663). The total procedure time was 8.9 minutes (interquartile range 7.5–10.3) and 9.3 minutes (interquartile range 7.2–10.9) in the snare-tip and ESD knife groups, respectively (P = 0.550). The local recurrence rate was 0% in both groups. No perforations were observed in either group.DISCUSSION:EMR-P using a snare-tip was noninferior to EMR-P using a ESD knife for large nonpedunculated colorectal polyps. EMR-P using a snare-tip is considered as effective and safe as an ESD knife.