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Europeans Report Japanese-Like en Bloc and R0 Colonic Endoscopic Submucosal Dissection Rates Using Double-Clip Traction

Douglas K. Rex, MD, MASGE, reviewing Bordillon P, et al. Gastrointest Endosc 2021 Feb 3.

Colonic endoscopic submucosal dissection (ESD) is generally considered more challenging than esophageal, stomach, or rectal ESD. 

The authors have previously described a double-clip traction (DCT) method that involves a clip on the anal side of the specimen, a clip on the wall opposite the specimen, and a rubber band connecting the two clips, which elevates the lead edge of the specimen and provides traction. In previous studies, this tool improved the R0 resection rate, reduced the perforation rate from 15% to 5%, and decreased ESD time by half. 

Five operators used the technique in 599 consecutive colonic ESDs, although 17% of lesions were excluded (recurrent lesions, appendiceal or diverticular location, lesions with tattoos, ileal location, inflammatory bowel disease-associated dysplasia, or submucosal lesions).

Fifty-seven percent of lesions were granular laterally spreading tumors (LSTs), and the overall en bloc resection rate was 95.7%, the R0 resection rate was 83.5%, and the perforation rate was 4.9%. There were 18 patients with superficial submucosal invasion (SMI) and 24 with deep SMI; 3 of these were T2. Patients who underwent surgery included 26 for path features and 4 for perforation, leaving 15 patients (2.5%) who avoided surgery by undergoing ESD. The mean procedure time was 62.4 minutes for lesions with a mean size of 53 mm. The recurrence rate at the first follow-up was 3%.

Douglas K. Rex, MD, FASGE


These results suggest that the DCT method or another traction method is advisable for colonic ESD. Limitations include the large number of granular LSTs, which have a low risk of cancer, and a number needed to treat of 40 to prevent one surgery.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.


Bordillon P, Pioche M, Wallenhorst T, et al. Double-clip traction for colonic endoscopic submucosal dissection: a multicenter study of 599 consecutive cases (with video). Gastrointest Endosc 2021 Feb 3. (Epub ahead of print) (

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