Traction Techniques for Endoscopic Submucosal Dissection (ESD): Organ-Specific Best Practices and Western Outcomes

ESD adoption in Western countries has been limited by longer procedure times, higher complication rates, and a steeper learning curve than in Eastern centers. This review examines the rationale for traction in Western practice, compares outcomes of traction-assisted versus conventional ESD, and outlines best practices for common techniques.

Traction methods such as clip-with-line, clip-and-snare, internal elastic devices, double-scope, and novel single-operator tools function as a "third hand" to improve submucosal visualization and dissection. Meta-analyses show that traction shortens procedure time (~20 minutes), increases R0 resection rates, and may reduce perforation risk-benefits most evident in the esophagus and colon. Western data are emerging: an expert U.S. center found no major differences with selective use, whereas Japanese RCTs and European guidelines support routine traction in defined settings. Traction addresses key challenges in Western ESD. Mastery of multiple methods allows tailored use, shortens the learning curve, and improves efficiency and safety.