Post written by Hiroyuki Aihara, MD, PhD, from the Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA.

Adequate visualization of the submucosal dissection plane is critically important for both safety and efficacy in endoscopic submucosal dissection (ESD). Recently, a novel clip-band traction device was introduced to the U.S. market (Elastic Traction Device; Micro-Tech Endoscopy USA Inc, Ann Arbor, Mich), specifically indicated for providing traction in ESD. The device consists of 3 interconnected elastic silicone bands, preloaded onto a standard 11-mm hemostatic clip.

There are 2 strategies for traction using this device. In the manufacturer-specified strategy (Case 1), the device is deployed along the mucosal edge after a circumferential mucosal incision. The other end of the elastic band is grasped with a second hemostatic clip, which is then deployed along the mucosal edge on the opposite side of the lesion.  This provides countertraction in an edge-toward-center direction. After the resection is complete, both clips are removed along with the specimen.

In an alternative strategy (Case 2), the clip-band device is also deployed along the mucosal edge. The other end of the elastic band is grasped with a second hemostatic clip, which is then deployed along the opposite wall of the lumen, slightly distal from the first clip. This provides traction in an upward-and-away direction from the area of dissection. After the resection is complete, the clip can be gently removed from the luminal wall using rat-toothed forceps.

In Case 3, defect closure using this device is demonstrated. First, the device is deployed at the anal side of the defect. Then, the inner elastic band was grasped using another clip and is fixed at the oral side of the defect for approximation of the short axis of the defect. This approximation facilitates complete clip closure of the large resection defect. The patient was discharged home with an uneventful postoperative course after restarting anticoagulation immediately after the procedure.

A major advantage of traction in ESD is that it decreases the reliance on gravity, as patients in the U.S. are often sedated under general endotracheal anesthesia and are thus difficult to reposition. Defect closure after colorectal ESD is often challenging, as ESD defects are often prohibitively large for standard clip closure, and an endoscopic suturing device mounted on a double channel gastroscope typically cannot reach the right colon.

The clip-band traction device provides versatile and effective traction and a secure defect closure in ESD. The simple clip-band device represents a low-cost yet valuable option to providing effective countertraction and defect closure. Future prospective studies are necessary to compare different modalities of tissue retraction and defect closure in ESD with regard to clinical efficacy and cost-effectiveness.

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