Multitraction with a single rubber band and clips: a simple tip for endoscopic submucosal dissection of a recurrent lesion with previous clip.

Endoscopic submucosal dissection (ESD) with double-clip traction (DCT) with a rubber band and two clips allows excellent en bloc and curative resection rates and is probably the cheapest traction system available [1]. Incomplete previous resection or recurrence is associated with a higher piecemeal resection rate [2] and severe fibrosis is an independent predictor of perforation [3]. DCT is also safe and effective in these settings [4]. Multipolar traction has been reported to improve the visualization of the submucosa with four peripheral rubber bands fixed with four clips on the edges and attached to a central band that is fixed on the opposite wall with a fifth clip [5]. This is effective but requires some time to set up the device, which can be difficult to advance up through a thin operative channel.