Various traction methods, including intraluminal traction for endoscopic submucosal dissection (ESD), have proven useful [1] [2]. Due to the stomach’s complex shape, devices providing only longitudinal traction externally are less effective [3]. The multi-loop traction device (MLTD; Boston Scientific, Marlborough, Massachusetts, United States), which enables traction-assisted ESD by anchoring the loop to the lumen of the other side with an endoscopic clip, allows for easy adjustment of traction direction and removal, demonstrating its effectiveness [4]. However, in the wide lumen of the stomach, a single short MLTD would result in excessive traction force and muscle-layer traction. Therefore, we report a safer gastric ESD technique using two connected MLTDs to optimize traction force and prevent excessive muscle-layer traction.

In Case 1, a single MLTD (triple loop) ([Fig. 1] a) was used. The lesion (19×16 mm, 0–IIc) was in the lesser curvature of the middle stomach ([Fig. 2]). ESD was performed using a DualKnife J (KD-655L; Olympus, Tokyo, Japan; [Video 1]), and an MLTD was applied after a circumferential incision. Although traction improved submucosal visibility, the muscle layer was also tractioned, making the procedure difficult ([Fig. 3]).

Fig. 3 Traction with a single multi-loop traction device (triple loop). Although traction improved the visibility of the submucosa, the muscle layer was also tractioned, which made the procedure difficult.

In Case 2, two MLTDs connected by a cow-hitch knot were used (six loops) ([Fig. 1] b). The lesion (10×6 mm, 0–IIa) was on the posterior wall of the midbody ([Fig. 4]). After making a full circumferential incision, traction with two MLTDs provided clear submucosal visibility without excessive muscle-layer traction ([Fig. 5]). ESD was safely completed using devices of appropriate length for the wide lumen. Distant anchoring can pull the muscle layer even with two MLTDs; therefore, the best site is slightly mouthward on the contralateral side.