Hemorrhage control during gastric endoscopic submucosal dissection: Techniques using uncovered knives

Abstract

Since the last decade, endoscopic submucosal dissection (ESD) has been used as the standard treatment for superficial gastrointestinal neoplasms. Trainees learning ESD frequently encounter difficulties such as vascularity, peristalsis, and fibrosis during the procedure. Because individual vascularity differs, it generally cannot be consistently avoided. Given that massive hemorrhages can prolong the procedure time and diminish treatment efficacy and that insufficient vessel handling may also increase postoperative bleeding, hemorrhage control during ESD becomes important to ensure procedure safety. This article discusses methods for controlling hemorrhage during gastric ESD. Endoscopists should have a basic understanding of the vascular architecture and the high‐density areas in blood vessels, which are susceptible to intraoperative hemorrhage. Efficient preventative coagulation should be performed in addition to mastering the techniques for hemorrhage control using hemostatic forceps. Techniques useful for preventing intraoperative hemorrhage at every step (e.g. submucosal injection, mucosal incision, and dissection) should be learned. Gaining procedural competence and learning hemorrhage control techniques not only during ESD but also in daily work would help provide safe and effective treatment.

Diode Laser—Can It Replace the Electrical Current Used in Endoscopic Submucosal Dissection? (with Video)

“…Bleeding is one of the most common complications associated with ESD, as intraprocedural bleeding interferes with precise endoscopic resection under a clear view of the operating field, which can lead to longer procedure times or an increase in the frequency of complications, such as perforation. 4 The incidence rates of immediate and delayed bleeding associated with gastric ESD are approximately 22% and 4.5%-5.5%, respectively. [5][6][7] A recent meta-analysis showed that the incidence rates of immediate and delayed bleeding associated with colorectal ESD are 0.82% and 1.7%, respectively.…”

Efficacy of the specialized scissor-type knife for gastric endoscopic submucosal dissection: a propensity score matched retrospective study

“…During ESD, control of complications is important, as is a high resection rate. Reduced intraoperative bleeding provides better visualization of the submucosal layer, allowing the operator to complete gastric ESD without stress, thereby improving ESD performance 37 38 39 . Akahoshi et al 40 reported that in most cases of gastric ESD, hemostasis was achieved using the CC alone; the rate of massive intraoperative bleeding was 0 %.…”

Electrosurgery in Gastrointestinal Endoscopy: Bench to Bedside

“…Conversely, for vessels with diameters 2 mm or for patients at an increased risk of hemorrhage, hemostatic forceps is preferred to ensure complete hemostasis by thermocoagulation in the soft coagulation mode (effect 4-5, 80 W; VIO300D). 6 After grasping with the forceps, it is important to gently pull back the vessel to avoid transmission of current in the deeper layers of the GI wall. Since the colonic walls are thinner as compared to the gastric wall, a smaller coagulation forceps with lower opening width (4 vs. 5 and 6.5 mm) is preferred.…”