Countertraction during endoscopic submucosal dissection (ESD) is indispensable, as it improves submucosal exposure, reduces procedure time and risk of bleeding or perforation, and improves en bloc resection rates. Common methods include patient repositioning, underwater ESD, and the off-label clip-and-line or rubber band technique. However, these techniques provide a limited traction direction and clips may slip off. A so called official ‘’third-arm’’ has been lacking in flexible gastrointestinal (GI) endoscopy.

Tracmotion  (FujiFilm, Tokyo, Japan) is a single-use, through-the-scope (TTS) traction device consisting of two interconnected parts: a scope‐mounted hand controller and a distal end with 360° rotatable grasping forceps. A dual‐channel endoscope is needed with a 3.7 mm or larger instrument inner channel diameter when using this traction device. 

Five trial ESDs using this novel traction device were performed to allow the endoscopist to become familiar with its use. To investigate the additional value of the traction device, mean procedure time and dissection speed with the device were compared to the averages without the device from 2022 to 2024 at the Erasmus Medical Center (EMC) in Rotterdam, the Netherlands.  After the trial ESDs, a total of 13 ESDs with the device were performed (5 upper GI, 8 lower GI). Among the upper GI cases, 4 patients were male, with a median age of 58 years (IQR 12); the mean lesion size was 13.0 mm (95% CI: 7.2–18.8). For the lower GI cases, 7 patients were male, with a median age of 60 years (IQR 13); the mean lesion size was 24.4 mm (95% CI: 19.2–29.6). Lesion locations at the upper GI included the body (n=1) and antrum of the stomach (n=3), and one in a gastric tube reconstruction after esophagectomy. Lower GI lesions were located in the rectum (n=6) and sigmoid colon (n=2). The stiffness of the dual-channel endoscope with limited angulation and space to maneuver precluded the use of the traction device for lesions near the rectal verge and in the esophagus. 

Procedure time was shorter with the device for both upper and lower GI cases (-16.7% and –19.1%, respectively), as shown in table 1. Dissection speed was also faster with versus without the device (1.5 mm²/minute faster for upper GI cases and 2.9 mm²/minute faster for lower GI cases). All resections were performed en bloc, with all but two lower GI ESDs achieving R0 resection. Post-ESD bleeding occurred after one upper GI ESD; the patient underwent an additional endoscopy with successful clip placement. In addition, one patient was hospitalized for post-polypectomy fever that resolved without intervention.

Table 1. Procedural characteristics 

CI: confidence interval; GI: gastrointestinal; EMC: Erasmus University Medical Center 

Both procedure time and dissection speed improved with the implementation of the novel traction device compared to the averages at the EMC without the device. In addition, there were no higher rates of complications compared to previous literature. These preliminary findings might suggest that the traction device could be of additional value during ESD. Further research, including more patients and additional questionnaires on the endoscopist’s personal experience with the device, is needed to better explore this topic.