Introduction and background

Esophageal cancer can be squamous cell cancer, which predominates in the Asian population and typically arises in the mid-esophagus, while esophageal adenocarcinoma predominates in the Western population and arises at the gastroesophageal junction in the setting of Barrett's esophagus [1]. Endoscopic submucosal dissection (ESD) is widely used for treatment of superficial esophageal cancers and precancerous lesions [1]. The other endoscopic treatment option for these lesions is endoscopic mucosal resection (EMR). Recent studies have shown that ESD demonstrates superior en-bloc resection rates compared to EMR [1-3]. The resection size and shape can be more carefully controlled with ESD compared to EMR [2,4,5]. However, ESD is a more technically challenging procedure associated with longer procedural time and increased risk of adverse events compared to EMR [5,6].

Resection quality in ESD is best understood as a hierarchy of increasingly stringent endpoints. En-bloc resection refers to removal of a lesion as a single, non-fragmented piece, allowing accurate pathological staging, but it does not indicate complete tumor clearance. R0 resection refers to histological evidence of free vertical and horizontal margins from the resected en-bloc tumor specimen. Curative resection is the most stringent endpoint requiring R0 margins along with absence of poorly differentiated histology, lymph vascular invasion, and invasion beyond the superficial submucosa [1-4]. Moreover, curability by endoscopic resection is closely related to the depth of invasion, with lesions confined to the mucosa carrying low risk of lymph node invasion and can be managed with just curative endoscopic resection, whereas lesions invading the submucosa carry higher risk of lymph node spread requiring adjuvant therapy or esophagectomy irrespective of the resection technique used [4].

ESD for the treatment of early esophageal neoplasms can be particularly challenging due to the narrow lumen and thinner wall of the esophagus [7,8]. As the esophageal ESD proceeds, the mobility of the lesion also increases, with the lesion moving towards the anorectal region, which makes visualization difficult [9]. Hence, esophageal ESD requires more technical expertise and is associated with prolonged procedural times compared to ESD at other locations [10-12]. Moreover, esophageal ESD has been associated with adverse events including perforation, bleeding, pneumomediastinum, and mediastinitis [13,14]. To overcome these problems, traction techniques have been developed to increase exposure, reduce tissue mobility, and potentially make ESD both faster and technically easier.

Traction-associated ESD (TA-ESD) has been increasingly used [10,15]. TA-ESD involves the application of countertraction after dissecting the mucosa, which increases separation between tissue planes and facilitates better visualization of the space between the mucosa and deeper muscle layer [10]. Traction promotes more efficient tissue dissection, which, in turn, can contribute toward shortening procedure duration. Traction can be applied by various techniques including clips with thread, traction clips, ring-shaped thread, and forceps. Studies have shown increased efficacy with fewer adverse events associated with TA-ESD, although results have been limited by small sample sizes [16,17].

With the widespread adoption of both techniques and the growing volume of published data, there is a need for a comprehensive comparison between the two. There is no reported meta-analysis comparing TA-ESD and C-ESD specifically for esophageal cancers. We conducted a meta-analysis to determine the pooled rates of efficacy and safety of TA-ESD vs C-ESD in the treatment of esophageal cancers.

This article was previously presented as a meeting abstract at the 2025 Digestive Disease Week (DDW) Annual Scientific Meeting on May 3, 2025 [18].