“Umbrella-shaped pulley traction” assisted endoscopic submucosal dissection of colonic lesions - a modified external traction technique

Sep 30, 2026

Uploaded by moss~

Umbrella-shaped pulley traction is presented as a modified external traction technique to improve endoscopic submucosal dissection (ESD) for colorectal laterally spreading tumors (LSTs), where visualization of the submucosal layer is technically demanding. The method addresses limitations of prior traction approaches by enabling multi-point, multi-directional traction. A 69-year-old woman with a 2cm×3cm rectal LST underwent ESD using a clip-and-dental-floss system forming an umbrella-shaped pulley structure to provide clear exposure and complete removal. The authors report the technique as innovative and suitable for larger or low-gravity lesions.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Clinical Rationale

Technique Description

Procedure Steps

Clinical Case and Outcome

Contributors and Declarations

References

Article published online: 2026-01-08 “Umbrella-shaped pulley traction” assisted endoscopic submucosal dissection of colonic lesions – a modified external traction technique Video 1 “Umbrella-shaped pulley traction” assisted endoscopic submucosal dissection of an extensive LST in the rectum. LST, laterally spreading tumor. Colorectal endoscopic submucosal dissection (ESD) is technically demanding because of the difficulty in adequately visualizing the submucosal layer. Therefore, building good traction to provide a clear view for ESD is critically important. Gravity, injection fluid, or a clip-with-line approach has been used to optimize traction during ESD to improve performance [1] . However, the traction direction and ability are limited in most traction methods, resulting in insufficient effects in some cases [2] . Therefore, we adopted a new multi-point and multi-directional external traction method (umbrellashaped pulley traction) to treat a case of extensive laterally spreading tumors (LSTs) in the rectum ( ▶Video 1) . A 69-year-old woman was found to have a LST (granular type and nodular mixed type) in the rectum. Endoscopic ultrasound indicated that the lesion originated from the mucosal layer and was approximately 2cm×3cm ( ▶ Fig.1) . Therefore, she received ESD for this lesion. Firstly, a circumferential incision was performed by submucosal injection atthe base of the lesion. At the three equal points along the edge of the lesion, a metal clip carrying dental floss was ▶Fig. 1 a Colonoscopy indicated an LST lesion in the rectum, as a nodular mixed type. b The ultrasound endoscope indicates that it originates from the mucosal layer, and the submucosa is intact. LST, laterally spreading tumor. ▶Fig.2 a A circumferential incision was performed by submucosal injection at the base of the lesion. b At the three equal points along the edge of the lesion, a metal clip carrying dental floss was clamped respectively, and then, three pieces of dental floss were placed ina metal ring outside the body. c The metal ring was sent into the body with a metal clip and clamped onto the mucosa on the opposite side of the lesion. d Formation of an umbrellashaped pulley traction structure. e Excised gross specimens. f The wound surface was clean and smooth. respectively clamped. Subsequently, three pieces of dental floss are placed ina metal ring outside the body. The metal ring was sent into the body with a metal clamp and clamped onto the mucosa on the opposite side of the lesion to form an“umbrella-shaped pulley” structure. The corresponding dental floss can be pulled outside the body as needed to achieve precise traction, allowing the submucosa to be better exposed, providing a clear operational field of view for ESD, and ultimately the lesion is completely removed, ensuring a smooth surgical process ( ▶ Fig.2 , ▶ Fig.3) . E26 Xie Rui et al. “Umbrella-shaped pulley traction” … Endoscopy 2026; 58: E26–E27 | © 2026. The Author(s) . ▶Fig.3 a A circumferential incision was performed by submucosal injection at the base of the lesion. b Umbrella-shaped pulley traction. This “umbrella-shaped pulley” traction overcomes the limitations of the previous unidirectional traction, allowing for multi-point and multi-directional traction, which is more convenient to operate. It helps to quickly, completely and safely separate the lesion, especially suitable for larger areas or lesions with low gravity. It is innovative and worth promoting. Endoscopy_UCTN_Code_TTT_ 1AQ_ 2AD_ 3AD Contributors ʼ Statement Rui Xie: Conceptualization. Ru Feng: Writing – original draft. Xiaozhong Yang: Project administration. Honggang Wang: Supervision. Weijie Dai: Writing – review & editing. Funding Information Scientific Research and Innovation Team of Huai ’ an First People ’s Hospital YCT202305 Jiangsu Provincial Medical Key Discipline Cultivation Unit JSDW202233 ‡ These authors contributed equally. Conflict of Interest | Th

FAQs

Why is traction important for colorectal endoscopic submucosal dissection (ESD)?

ESD is technically demanding because the submucosal layer is difficult to visualize adequately. Building effective traction provides a clear view, which is critical for performance.

What problem do previous traction methods have?

Most traction methods restrict traction direction and traction ability, which can lead to insufficient traction effects in some cases.

How does the umbrella-shaped pulley traction technique work?

Metal clips carry dental floss at multiple points along the lesion edge, and the floss is routed through a metal ring outside the body. By pulling the corresponding floss externally, the structure forms an umbrella-shaped, multi-point and multi-directional traction to expose the submucosa and support complete lesion removal.

Sep 30, 2026

Uploaded by moss~