Post written by Shuichi Miyamoto, MD, PhD, from the Department of Gastroenterology and Hepatology, Hakodate Municipal Hospital, Hakodate, and the Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan.

Recently, the effectiveness of traction-assisted ESD has been reported, and there are various devices for applying countertraction. These reported devices permit the traction for 1 point of the mucosa per 1 device and are generally attached to the front-side mucosa of tumors.

We modified the traction device and method for large colorectal tumors needing multi-traction. First, three 15-mm-diameter ring-threads of 5-0 nylon were tied to the long clip. This triple-loop clip was attached to the normal mucosa on the opposite side of the tumor. Each of the loops were individually deployed to tumor mucosa using a short clip after submucosal injection. This triple-loop clip method was named the “multidirectional triple-loop traction method (MTL-traction method).” We showed 2 colorectal ESD cases dissected with the MTL-traction method.

Other traction devices reported in the past only allow traction for 1 point of the mucosa per device. However, with our device, we could obtain up to 3-point tractions per MTL-traction device. If the endoscopist feels that 1- or 2-point tractions are enough for the tumor, they can use only 1 or 2 loops and leave the other loops unused. When the endoscopist wants to add more point tractions as submucosal dissection progresses, they can use surplus loops to make up to 3 tractions. With the possibility of creating multi-tractions when and where required, these 2 cases showed that the MTL-traction method has a high versatility to make up to 3 tractions. We propose that this new MTL-traction method makes colorectal ESD easy and safer for all endoscopists, from beginner to expert.

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