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Competing Interests: J. Rivory, L.-J. Masgnaux, J. Grimaldi, and M. Pioche are co-founders of ATRACT devices and Co. E. De Cristofaro, T. Fenouil, and P. Lafeuille declare that they have no conflict of interest.

Competing Interests: Jérôme Rivory, Jean Grimaldi, Louis-Jean Masgnaux, Mathieu Pioche are co-founders of the ATRACT devices and co. Nothing to declare for the other authors.

Competing Interests: J. Rivory, L. J. Masgnaux, J. Jacques, and M. Pioche are co-founders of the ATRACT devices and co. E. De Cristofaro, T. Wallenhorst, and P. Lafeuille declare that they have no conflict of interest.

Competing Interests: Jérôme Rivory, Jean Grimaldi, Louis Jean Masgnaux, Mathieu Pioche are co-founders of the ATRACT devices and co. Nothing to declare for the other authors.

Competing Interests: J. Jacques, M. Pioche, J. Rivory, and L.-J. Masgnaux are co-founders of ATRACT Devices and Co. E. De Cristofaro, A. Lupu, and T. Wallenhorst declare that they have no conflict of interest.

Competing Interests: Jérôme Rivory, Louis-Jean Masgnaux, Jean Grimaldi, Mathieu Pioche are co-founders of the ATRACT devices and co. Nothing to declare for the other authors

Competing Interests: J. Grimaldi, L.-J. Masgnaux, T. Wallenhorst, J. Rivory, J. Jacques, and M. Pioche are founders of the company ATRACT Device and Co. A. Lupu declares that he has no competing interest.

Competing Interests: Louis-Jean Masgnaux, Jean Grimaldi, Timothée Wallenhorst, Jérôme Rivory, Jérémie Jacques and Mathieu Pioche are shareholders of the company ATRACT device & Co. Valerie Hervieu does not have any conflict of interest to declare.

Competing Interests: J. Grimaldi, L.-J. Masgnaux, T. Wallenhorst, J. Rivory, J. Jacques, and M. Pioche are co-founders of the company ATRACT Device & Co. E. De Cristofaro declares that she has no conflict of interest.

Competing Interests: Jérôme Rivory, Louis-Jean Masgnaux, Mathieu Pioche are co-founders of the ATRACT devices and co. Nothing to declare for the other authors.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: J. Rivory, L.-J. Masgnaux, and M. Pioche are cofounders of ATRACT Devices and Co. E. De Cristofaro J. Jacques, T. Wallenhorst, and P. Lafeuille declare that they have no conflict of interest.

Competing Interests: J. Jacques, M. Pioche, J. Rivory, and L.-J. Masgnaux are co-founders of the ATRACT devices and co. E. De Cristofaro and J. Grimaldi declare that they have no conflict of interest.

Background: The ileocecal valve (ICV) is considered to be one of the most difficult locations for endoscopic submucosal dissection (ESD). The objective of this study was to evaluate the efficacy and safety of traction-assisted ESD in this situation., Methods: All patients who underwent traction-assisted ESD for an ICV lesion at three centers were identified from a prospective ESD database. En bloc and R0 rates were evaluated. Factors associated with non-R0 resection were explored., Results: 106 patients with an ICV lesion were included. The median lesion size was 50 mm (interquartile range 38-60) and 58.5% (62/106) invaded the terminal ileum. The en bloc and R0 resection rates were 94.3% and 76.4%, respectively. Factors associated with non-R0 resection were lesions covering ≥75% of the ICV (odds ratio [OR] 0.21. 95%CI 0.06-0.76; P=0.02), and involving the anal lip (OR 0.36, 95%CI 0.13-0.99; P=0.04) or more than two sites on the ICV (OR 0.27, 95%CI 0.07-0.99; P=0.03)., Conclusion: Traction-assisted ESD for treatment of ICV lesions was a safe and feasible option. Large lesions and anal lip involvement appeared to be factors predictive of difficulty., Competing Interests: C. Yzet is a consultant and lecturer for Abbvie, Takeda, Jansen, Amgen, and Galapagos. T. Wallenhorst has received honoraria for ESD training sessions from Olympus and Fujifilm, and lectures for Mayoli. J. Jacques has provided ESD training sessions for Olympus, Fuji, Erbe, Pentax Medical, and Lumendi, and lectures for Abbvie, Janssen, and Norgine. J. Rivory has received honoraria for training sessions in endoscopy and endoscopic resection from Olympus and Cook Medical. M. Schaefer has received honoraria for training session from Boston Scientific, and has received invitations to congresses from Olympus, Cook, Cousin Medical, Boston, Pentax, Abbvie, MSD, Amgen, and Norgine. M. Pioche has received honoraria for training sessions in endoscopy and endoscopic resection from Olympus, Cook Medical, Boston Scientific, and Pentax Medical; honoraria for training sessions in endoscopic characterization from Norgine and Provepharm; invitation to UEGW from AlfaSigma; and owns a patent for the Hospices Civils de Lyon IPEFIX device. M. Figueiredo, F. Rostain, L.J. Masgnaux, J. Grimaldi, R. Legros, P. Lafeuille, J. Albouys, and F. Subtil declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background and Aims: Traction has become the reference strategy for colorectal endoscopic submucosal dissection (ESD). One of its major limitations is that the force of traction decreases as dissection progresses. The ATRACT traction device (ATRACT Device and Co, Lyon, France) uses a pulley system to increase traction during the procedure, making it easier and faster. A retrospective study of 54 cases showed interesting results in terms of efficacy and safety throughout the digestive tract. We sought to confirm these initial results with a prospective study of resections of colorectal lesions., Methods: In this prospective multicenter study, 5 experienced operators from 3 different centers each performed 10 procedures using the ATRACT device consecutively for all conventional colorectal ESDs measuring between 4 and 10 cm in conventional locations (no recurrent lesions, appendicular, of the ileocecal valve, in contact with the pectinate line, or measuring more than two-thirds of the circumference)., Results: Between November 2022 and April 2023, 50 ESDs were performed in 49 patients. On average, the main diameter of the lesions was 66.6 mm, with a surface area of 3066 mm 2 . The mean operating time was 55.2 minutes, resulting in a mean resection speed of 61.4 mm 2 /min. En bloc and R0 resection rates were 100% and 98%, respectively. Resections were curative in 94% of cases. Four (8%) perforations occurred, all of which were closed endoscopically without the need for surgery. One (2%) case of delayed hemorrhage was noted. To date, this is the series with the highest resection speeds in the literature for colorectal ESD. For comparison, previous studies reported a speed of 23.5 mm 2 /min using the "pocket" strategy and a speed of 39.1 mm 2 /min using the double-clip traction technique. These results need to be confirmed in larger studies and in nonexpert centers., Conclusions: This prospective evaluation confirms the efficacy and safety of the adaptive traction strategy with the ATRACT device for colorectal ESD with high resection speed., Competing Interests: Disclosure The following authors disclosed financial relationships: J. Grimaldi: Cofounder of ATRACT Device and Co. L.-J. Masgnaux: Cofounder of ATRACT Device and Co. J. Rivory: Cofounder of ATRACT Device and Co; training sessions in endoscopy for Olympus, Cook Medical, and Boston scientific. R. Legros: Cofounder of ATRACT Device and Co; training sessions in endoscopy for Olympus, Fuji, and Erbe. T. Wallenhorst: Training sessions in endoscopy for Olympus and Fujifilm. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: The management of bulky neoplastic lesions in the digestive tract has historically been a surgical pursuit. With advancements in endoscopic techniques, particularly endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), a paradigm shift toward organ preservation has been initiated. These endoscopic methods, developed incrementally since the 1980s, have progressively enabled curative management of lesions with minimal morbidity, challenging the previously unchallenged domain of surgery., Summary: This review traces the evolution of endoscopic resection from snare polypectomy and EMR to sophisticated ESD, highlighting the technological innovations that have expanded the scope of endoscopic resection. It discusses the intricacies of various EMR techniques like underwater EMR, anchoring EMR, and hybrid EMR, alongside traction-assisted methods and the use of viscous solutions for submucosal injection. Additionally, the manuscript delves into the advancements in ESD, emphasizing traction strategies, knife technology, and the optimization of endoscopes. The benefits of these advancements are weighed against the challenges in anatomopathological interpretation posed by piecemeal resections., Key Messages: The continuous amelioration of endoscopic resection techniques has significantly improved the outcomes of digestive tract lesion management, particularly in achieving R0 resections and reducing recurrence rates. These advancements represent a monumental step toward minimizing the invasiveness of lesion management. However, despite the progress, the necessity for early follow-up post-EMR remains due to the non-negligible recurrence rates, underscoring the need for a rigorous postoperative surveillance regimen. Furthermore, our review suggests that while ESD has transformed the therapeutic landscape, its widespread adoption hinges on further simplification, safety enhancement, and acceleration of the procedure, possibly through innovations like adaptive traction devices., Competing Interests: All authors are shareholders of the company “ATRACT device & Co.”, (© 2024 S. Karger AG, Basel.)

Competing Interests: J. Rivory, J. Jacques, R. Legros, T. Wallenhorst, and M. Pioche are co-funders of the ATRACT device, and also consultants for Olympus, Pentax, Erbe, and Boston for training in ESD. L.-J. Masgnaux is the inventor of the ATRACT device. The Ipefix patent is the property of the institution Hospices civils de Lyon. J. Albouys declares that he has no conflict of interest.

BACKGROUND : Good submucosal exposure is key to successful endoscopic submucosal dissection (ESD) and can be achieved with various traction devices. Nevertheless, these devices have a fixed traction force that tends to decrease as the dissection progresses. In contrast, the ATRACT adaptive traction device increases traction during the procedure. METHODS : In this retrospective analysis of prospectively collected data (from a French database), we analyzed ESD procedures performed with the ATRACT device between April 2022 and October 2022. The device was used consecutively whenever possible. We collected details of lesion characteristics, procedural data, histologic outcomes, and clinical consequences for the patient. RESULTS : 54 resections performed in 52 patients by two experienced operators (46 procedures) and six novices (eight procedures) were analyzed. The ATRACT devices used were the ATRACT-2 (n = 21), the ATRACT 2 + 2 (n = 30), and the ATRACT-4 (n = 3). Four adverse events were observed: one perforation (1.9 %), which was closed endoscopically, and three delayed bleeding events (5.5 %). The R0 rate was 93 %, resulting in curative resection in 91 % of cases. CONCLUSION:  ESD using the ATRACT device is safe and effective in the colon and rectum, but can also be used to assist with procedures in the upper gastrointestinal tract. It may be particularly useful in difficult locations., Competing Interests: L.-J. Masgnaux, J. Grimaldi, J. Rivory, T. Wallenhorst, R. Legros, J. Jacques, and M. Pioche are cofounders of A-TRACT Device & Co. T. Ponchon, C. Yzet, A. Lupu, and F. Rostain declare that they have no conflict of interest., (Thieme. All rights reserved.)

Competing Interests: J. Jacques, M. Pioche, J. Rivory, and L. J. Masgnaux are cofounders of the ATRACT devices and company. E. De Cristofaro, J. C. Saurin, and B. Napoléon declare that they have no conflict of interest.

Competing Interests: L.-J. Masgnaux, Mathieu Pioche and Jérôme Rivory are cofounders of the start up A-tract.

Competing Interests: All authors are founders of the company A-TRACT Device and Co and a patent has been demanded by our institution for the A-TRACT 2 + 2.

Competing Interests: A patent is demanded by our institution.

Competing Interests: The authors are founders of the A-TRACT company.

Competing Interests: A patent for the device has been requested by our institution.

Competing Interests: J. Jacques, L. J. Masgnaux, T. Wallenhorst, and M. Pioche are co-funders of the A-TRACT devices and company. E. De Cristofaro, P. Lafeuille, and C. Yzet declare that they have no conflict of interest.

Competing Interests: LJM: Co-Founder of A-TRACT device & co.CY: consultant and lectures for Abbvie, Takeda, Jansen, Amgen, Galapagos.JR: Honorary for Training sessions in endoscopy and endoscopic resection for Olympus, Cook Medical, Co-Founder of A-TRACT device & co.MP: Honorary for Training sessions in endoscopy and endoscopic resection for Olympus, Cook Medical, Boston scientific, Pentax Medical. Co-Founder of A-TRACT device & co.Honorary for Training sessions in endoscopic characterization with Norgine, Provepharm. Uegw invitation by AlfaSigma. Patent of our institution Hospices civils de Lyon for IPEFIX device.JJ: ESD training sessions: Olympus, Fuji, Erbe, Pentax, lumendi. Lectures: Abbvie, Janssen, norgine. Co-Founder of A-TRACT device & co.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: J. Rivory, L. J. Masgnaux, J. Grimaldi, and M. Pioche are co-funders of the A-TRACT devices. E. De Cristofaro, C. Yzet, and S. Leblanc declare that they have no conflict of interest.

Competing Interests: Our institution Hospices civils de Lyon has deposed a patent on this device.

Competing Interests: Pierre Lafeuille and Alexandru Lupu: nothing to disclose. Louis-Jean Masgnaux, Timothée Wallenhorst, Jérémie Jacques, Jérôme Rivory and Mathieu Pioche are cofounders of the company A-tract device & Co.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: Jean Grimaldi, Louis-Jean Masgnaux, Jérôme Rivory and Mathieu Pioche are founders of the company A-TRACT Device and Co.

Competing Interests: Our institution Hospices civils de Lyon has registered a patent on this device with a project of start up creation.

Competing Interests: J. Rivory, J. Jacques, R. Legros, T. Wallenhorst, and M. Pioche are co-funders of the ATRACT device, and also consultants for Olympus, Pentax, Erbe, and Boston for training in ESD. L.-J. Masgnaux is the inventor of the ATRACT device. The Ipefix patent is the property of the institution Hospices civils de Lyon. J. Albouys declares that he has no conflict of interest.

Competing Interests: Louis-Jean Masgnaux and Mathieu Pioche founded the company A-TRACT device & Co to develop the device they created.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Video 1Dissections of appendiceal lesions using A-TRACT-2., (© 2022 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)