Commentary

For over 20 years, multiple techniques and tools have evolved for the improvement of endoscopic submucosal dissection (ESD); nevertheless, optimizing mucosal lifting and access to the submucosal space remain fundamentally important. But the crucial elements of ESD performance can be obscured by the elaborations – “the devil is in the details.”

In this video, Pioche et al. present how some simple technical features, developed over time or shrewdly adjusted, have become instrumental in enhancing ESD performance. The use of a flex knife that enables replacement of conventional injection by high pressure injection with viscous solution, together with novel multipolar traction that can be varied as needed by the operator during the procedure, allows better access to the submucosal space [11] [22]. Additionally, the more precise visualization of deep-lying vessels and bleeding points by red dichromatic imaging also positively influences the procedure time and R0 achievement [33]. Ergonomic improvement by fixing the positions of the three foot pedals is another of the seemingly insignificant details, along with adequate scope selection and flexibility, that is beneficial in optimizing ESD performance.

These enhancements may be especially useful when risk factors for unsuccessful or challenging ESD persist, including large size of the lesion, difficult location, deeper submucosal invasion, or severe fibrosis [44]. These proposed tools may allow easier and more successful performance of ESD.

Publication History

Article published online:
28 February 2024

• References

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• 2 Grimaldi J, Masgnaux LJ, Rivory J. et al. Multipolar traction with adjustable force increases procedure speed during endoscopic submucosal dissection: the A-TRACT-4 traction device. Endoscopy 2022; 54: E1013-E1014
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