Clin Endosc.  2017 Nov;50(6):562-568. 10.5946/ce.2017.108.

Recent Development of Techniques and Devices in Colorectal Endoscopic Submucosal Dissection

  • 1Department of Gastroenterolog, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
  • 2Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.


Colorectal endoscopic submucosal dissection (ESD) is now a well-established endoscopic treatment for early-stage colorectal neoplasms, especially in Asian countries, including Japan. Despite the spread of colorectal ESD, there are still situations in which achieving successful submucosal dissection is difficult. Various novel techniques and devices have been developed to overcome these difficulties, and past reports have shown that some of these strategies can be applied to colorectal ESD. We review several recent developments in the field. The techniques reviewed include the pocket creation method and traction methods and the devices reviewed include the overtube with balloon and electrosurgical knives with water-jet function. These improved techniques and devices can facilitate safer, more reliable ESDs and expand its applicability and acceptability all over the world.


Colorectal endoscopic submucosal dissection; Pocket creation method; Traction method; Overtube with balloon; Electrosurgical knives with water-jet function

MeSH Terms

Asian Continental Ancestry Group
Colorectal Neoplasms


  • Fig. 1. Pocket creation method. (A) A colon tumor, such as a laterally spreading tumor. (B) A minimal mucosal incision is performed after submucosal injection. (C, D) The endoscope is inserted into the submucosal layer from the initial incision and submucosal dissection is performed in such a way as to make a pocket under the lesion. (E, F) Finally, incisions are made around the lesion to complete en bloc resection of the remaining mucosa.

  • Fig. 2. Traction methods. (A) External forceps method. (B) Clip-with-line method. (C) Clip-and-snare method with a pre-looping technique. (D) Clip-with-loops method.

  • Fig. 3. Endoscopic images of colonic endoscopic submucosal dissection using clip-with-loops method. (A) An early adenocarcinoma 25 mm in diameter in the transverse colon. (B) After the circumferential incision was performed, poor endoscopic maneuverability prevented the fine visualization of submucosal layer. (C) One side of the loop was anchored to the edge of the lesion using a clip. (D) Another clip was attached to the opposite side of the colon wall while grasping the loop. (E) Good traction was produced, enabling a better submucosal view and safer dissection. (F) En bloc resection was performed.

  • Fig. 4. Overtube with balloon. A picture of the ST-SB1 (Olympus, Tokyo, Japan) is shown. The inflated balloon improves scope stability and maneuverability during procedures.

  • Fig. 5. Electrosurgical knives for endoscopic submucosal dissection.

  • Fig. 6. Submucosal injection using water-jet function of the Splash M knife. (A) After mucosal incision, the submucosal layer was found to be too thin for a safe dissection. The tip of the Splash M knife (shown in the bottom of the image) was put on the submucosal layer for water-jet injection. (B) After injection, the thickened submucosal layer was effectively visualized.


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