Background: The diagnosis of early gastrointestinal cancer has progressed dramatically with the development of the NBI system.

In addition, the development of ESD has made it possible to remove large lesions unblocked, enabling accurate pathological diagnosis.

Aim: Until now, we have performed various counter-traction methods to keep a good field of view in ESD. We report the choice of the canter-traction method according to the tumor site.

Methods: From June 2010 to December 2018, ESD was performed on 173 cases of superficial esophageal cancer and 33 cases of hypopharyngeal cancer. After circumferential incision using clutch cutter, the proximal end of mucosa is grasped with the fine forceps or clip.

1.     Double-channel ESD using an EEMR-tube: Thin grasping forceps were inserted through the side channel of the EEMR-tube. The oral end of the circumferentially incised lesion is held with the forceps. As counter-traction is applied by gently pulling the forceps.

2.     Clip with line method combined with an Atom multipurpose tube: After circumferential incision, the proximal end of the mucosa is grasped with the clip. Counter-traction is applied by pulling the Atom tube after clipping.

3.     Double scope ESD using transnasal thin scope: Thin grasping forceps is inserted through the channel of the scope. The proximal end of the mucosa is grasped with the forceps. Counter-traction is applied by gently pulling the forceps with the thin scope.

Results: These techniques can be performed by always observing the sub mucosal dissected layer.

These were possible to perform the dissecting procedure safely, with no complications, such as perforation or bleeding in every case.

These techniques are expecting to shorten the time of ESD and avoid complications.

Conclusion: These techniques, which can be performed by always observing the sub mucosal or sub epithelial dissected layer under counter-traction, are also considered advantageous from viewpoint of safety.