Colorectal endoscopic submucosal dissection (ESD) remains technically challenging. Various traction methods have been developed to improve submucosal visualization; however, most provide traction along a single vector, limiting both exposure and stable maintenance of the dissection plane. 1 In addition, many methods require intracolonic grasping of a ring and may be complicated by ring slippage when fixation is attempted on the opposite colonic wall. 2 Although two-dimensional traction systems such as the ATRACT device can provide broader surface traction, they require a dedicated proprietary device and still share the same intracolonic ring-grasping limitation. 3
We therefore developed “Furoshiki traction,” a two-dimensional traction method based on the CLiPS technique 4 and ROLM 5 using only standard through-the-scope clips, without the need for intracolonic ring grasping ( Fig. 1 , Video 1 ).
Fig. 1.
Furoshiki Traction. ( a ) Distal clip-with-line placement. ( b ) Sequential marginal clip placement with threaded line. ( c ) Contralateral colonic wall fixation with clip. ( d and e ) Traction using the CLiPS technique. ( f ) Safe and rapid submucosal dissection.
Video 1 ESD on a 50-mm cecum using Furoshiki Traction.
A 66-year-old man presented with a 50 mm laterally spreading tumor in the cecum. After circumferential mucosal incision, a SureClip (Micro-Tech, Nanjing, China) preloaded with a suture thread was placed at the lesion margin. The thread was then passed through the hole in the arm of the next clip, which was deployed at an adjacent site. This procedure was repeated sequentially around the lesion periphery. A fixation clip was subsequently placed on the contralateral mucosa, and the thread was tightened using the CLiPS technique, thereby cinching the lesion edges and lifting the entire specimen in a manner resembling a traditional Japanese Furoshiki wrapping cloth. Traction strength was adjusted as needed, and the thread was then secured and cut.
This maneuver elevated the lesion in a tent-like fashion, producing both a flap-lifting effect through bilateral edge elevation and effective countertraction through fixation to the opposite wall. In addition, circumferential convergence reduced the submucosal dissection area geometrically, helping maintain excellent visualization throughout the procedure.
Furoshiki traction enables two-dimensional submucosal traction using only standard equipment, making it a simple, low-cost, and practical method for colorectal ESD.
Acknowledgement
We wish to express our deep appreciation to all endoscopy medical staff for their assistance with endoscopic procedures.
Footnotes
Conflict of Interest The authors declare that they have no conflict of interest.
Contributorsʼ Statement Susumu Banjoya: conceptualization, data curation, formal analysis, investigation, methodology, project administration, validation, visualization, writing – original draft, and writing – review and editing. Ken Ohata: conceptualization, investigation, methodology, supervision, and writing – original draft. Masaki Koga: investigation and Validation. Toshihiro Funabiki: investigation and validation. Shinya Nagae: investigation and validation. Shigenobu Yoshimura: investigation and validation. Ryoju Negishi: investigation, methodology, supervision, and validation.
Ethical approval
All procedures followed have been performed in accordance with the ethical standards laid down Declaration of Helsinki and its later amendments.
References
- 1.Jacques J, Charissoux A, Legros R et al. Double-clip counter-traction using a rubber band is a useful and adaptive tool for colonic endoscopic submucosal dissection. Endoscopy. 2018;50(02):179–181. doi: 10.1055/s-0043-122596. [DOI] [PubMed] [Google Scholar]
- 2.Ito M, Miura Y, Mizuguchi Y et al. Efficacy and safety of multi-loop traction device-assisted colorectal endoscopic submucosal dissection: Multicenter randomized clinical trial. Endosc Int Open. 2025;13:a24660718. doi: 10.1055/a-2466-0718. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Grimaldi J, Napoléon B, Masgnaux L Jet al. Endoscopic submucosal dissection of a laterally spreading tumor totally invading a deep sigmoidal diverticulum using an adaptive traction strategy Endoscopy 202355S 01E898–E899. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Takeuchi N, Ohata K, Kimoto Y et al. Clip with line-pulley securing technique with plastic detachable snare for endoscopic submucosal dissection defect closure. Video GIE. 2023;9(03):128–129. doi: 10.1016/j.vgie.2023.10.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Nomura T, Mitani T, Ikadai Yet al. A novel traction method for underwater colorectal endoscopic submucosal dissection: reopenable clip-over-the-line traction Endoscopy 202557S 01E837–E838. [DOI] [PMC free article] [PubMed] [Google Scholar]