While both traction-assisted (TRC) and pocket creation method (PCM) techniques have been developed to facilitate colorectal endoscopic submucosal dissection (ESD), yet comparative data remain limited. This study aimed to compare clinical outcomes between TRC and PCM, with a particular focus on dissection speed and factors influencing it.

256 consecutive colorectal ESD procedures were retrospectively analyzed at our institution (145 PCM, 111 TRC). Primary outcomes included en bloc resection, R0 resection, curative resection rates, and dissection speed. Secondary outcome includes adverse events. Statistical analysis included Fisher's exact test and the Chi-squared test for categorical variables and the Mann-Whitney U test for continuous variables. Multivariable Firth logistic regression adjusted for lesion size, lateral spreading tumor (LST) classification, anatomical location, gender, invasion depth, and fibrosis.

Both techniques achieved 100% en bloc resection with comparable R0 (98.6% PCM vs 100% TRC, p=0.214) and curative resection rates (91.0% PCM vs 96.4% TRC, p=0.088). Notably, mean dissection speed showed no statistical difference (48.6±29 mm²/min PCM vs 49.9±34.9 mm²/min TRC, p=0.722) with similar mean dissection times (43.7 vs 42.2 min, p=0.218). In univariate analysis, technique choice was not a significant determinant of dissection speed (p=0.344), while multivariable analysis revealed F2 fibrosis as the strongest determinant of dissection speed (p<0.001), and larger dissection size associated with faster speed (p=0.021). No significant differences were observed in adverse events (perforation: 0.7% PCM vs 1.8% TRC, p=0.581). PCM was predominantly used for rectal lesions (36.6% vs 6.3%, p<0.001), while TRC was preferred for colonic lesions. The PCM group had more carcinomas (33.8% vs 14.4%, p<0.001) and invasive lesions (17.2% vs 5.4%, p=0.004). LST morphology distribution differed significantly (p=0.017).

Both PCM and TRC techniques demonstrate equivalent efficacy in terms of en bloc, R0, curative resection, and safety profile, but neither technique provided a speed advantage. These findings support both PCM and TRC as valuable, complementary tools in colorectal ESD and indicate that technique choice should be guided by lesion characteristics rather than expectations of faster and safer dissection.