Comparative Effectiveness of Traction-Assisted and Conventional ESD for Gastric Neoplasia: Systematic Review and Meta-analysis

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Aims Traction-assisted endoscopic submucosal dissection (T-ESD) is designed to improve tissue exposure and facilitate safer, more efficient resections. However, comparative evidence across traction modalities remains heterogeneous. We conducted a meta-analysis evaluating the effectiveness and safety of T-ESD versus conventional ESD (C-ESD) for gastric neoplasia, including predefined subgroup analyses. Methods Five comparative studies (4 RCTs and 1 prospective cohort) comprising 1,514 gastric lesions were included. Effect sizes were pooled using random-effects models. Continuous outcomes were summarized as mean differences (MD), and binary outcomes as risk ratios (RR). Subgroup analyses assessed outcomes by traction modality, operator experience, and lesion location. Results A total of 758 lesions were resected with traction and 756 with standard ESD. Procedure time was significantly shorter with T-ESD (MD−9.7 minutes, 95% CI−16.6 to−2.8; 4 RCTs). R0 resection rates were comparable between groups (RR 1.01, 95% CI approximately 0.98–1.05). En-bloc resection was uniformly high in all studies (>95%) with no significant difference (RR ~1.00). Perforation occurred less frequently with traction (RR approximately 0.30). Delayed bleeding rates were nearly identical (RR: approximately 1.00). Subgroup analyses Traction method: All four modalities favored T-ESD, with the greatest reductions in procedure time observed for GTS-partner and CSM-PLT. Operator experience: Both experts (MD ~−9 min) and trainees (MD ~−9 min) demonstrated faster dissection with traction, with a consistent magnitude of benefit. Lesion location: T-ESD reduced procedure time in both the upper/middle and lower stomach (DFC pilot: MD−8 to−10 minutes). No subgroup showed loss of effectiveness or increased risk with traction. Conclusions Traction-assisted gastric ESD significantly reduces procedure time without compromising safety or curative resection outcomes. Benefits are consistent across different traction devices, operator experience levels, and lesion locations. T-ESD appears advantageous and may enhance efficiency even for less-experienced operators. Publication History Article published online: 05 June 2026 © 2026. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

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