Technical evolution in endoscopic submucosal dissection: The role of the water pressure method

The water pressure method (WPM) is an innovative technique in endoscopic submucosal dissection (ESD) that employs active waterjet pressure to expand the submucosal space in three dimensions. Rather than merely creating an underwater environment, WPM applies active hydrodynamic force to achieve superior visualization and precise dissection. This approach represents a step beyond immersion-based methods, offering distinctive benefits in complex anatomical settings. Originally developed to address the technical challenges of duodenal ESD, such as poor mucosal lifting, narrow lumen, and a thin muscularis propria, WPM has since been applied throughout the gastrointestinal tract. The underwater environment reduces gravity-dependent distortion, provides a magnified view, and minimizes luminal overdistension. Hydrodynamic pressure further supports submucosal pocket creation and facilitates precise handling of margins. Although current evidence remains limited to retrospective studies from expert centers, WPM extends the scope of ESD by enabling safe and effective dissection in regions once considered high risk. Its ability to enhance visualization and spatial control without depending solely on gravity or insufflation marks a significant conceptual advance in therapeutic endoscopy. With confirmation from prospective trials and broader adoption, WPM has the potential to become a new standard in advanced endoscopic practice.