Clin Endosc.  2013 Sep;46(5):456-462.

Preventing and Controlling Bleeding in Gastric Endoscopic Submucosal Dissection

• Park CH
• Lee SK

Abstract

Although techniques and instruments for endoscopic submucosal dissection (ESD) have improved, bleeding is still the most common complication. Minimizing the occurrence of bleeding is important because blood can interfere with subsequent procedures. Generally, ESD-related bleeding can be divided into intraprocedural and postprocedural bleedings. Postprocedural bleeding can be further classified into early post-ESD bleeding which occurs within 48 hours after ESD and late post-ESD bleeding which occurs later than 48 hours after ESD. A basic principle for avoiding intraprocedural bleeding is to watch for vessels and coagulate them before cutting. Several countertraction devices have been designed to minimize intraprocedural bleeding. Methods for reducing postprocedural bleeding include administration of proton-pump inhibitors or prophylactic coagulation after ESD. Medical adhesive spray such as n-butyl-2-cyanoacrylate is also an option for preventing postprocedural bleeding. Various endoscopic treatment modalities are used for both intraprocedural and postprocedural bleeding. However, hemoclipping is infrequently used during ESD because the clips interfere with subsequent resection. Bleeding that occurs as a result of ESD can usually be managed easily. Nonetheless, more effective ways to prevent bleeding, including reliable ESD techniques, must be developed.

Keyword

Endoscopic submucosal dissection; Hemorrhage; Prevention and control; Hemostasis

MeSH Terms

Adhesives
Enbucrilate
Hemorrhage
Hemostasis
Adhesives
Enbucrilate

Figure

• 

  Fig. 1 Examples of intraprocedural bleeding. (A) A saline solution containing epinephrine (0.01 mg/mL) mixed with indigo carmine was injected into the submucosal layer using a 21-gauge needle to lift the lesion from the muscle layer. (B) Bleeding from the injected site can be controlled relatively easily with strategies including spontaneous hemostasis, saline spray with diluted epinephrine, and compression with an endoscope tip. (C) Circumferential incision in the stomach upper body. (D) Bleeding from needle knife incision. Bleeding in the upper body occurs because of abundant submucosal blood vessels with large diameters. This bleeding is more serious than bleeding from injections. Bleeding from lesions comes into the endoscope cap, which is retroflexed, obscuring the vision. (E) Bleeding from insulated tipped knife incision. (F) Bleeding could not be identified here, and therefore (G, H) additional incisions were performed in order to see the bleeding source more clearly. Coagulation of the abundant vascular networks using a knife with swift mode was performed.

• 

  Fig. 2 Watch for vessels, and coagulate them before cutting to prevent intraprocedural bleeding. Understanding stomach anatomical characteristics such as large-diameter perforating vessels in the lesser body curvature is important. Submucosal dissection in this area should be cautious compared to the antrum. (A-C) During submucosal dissection, one large vessel was identified, and dissection was stopped. (D-F) Thermocoagulation hemostasis using hemostatic forceps was performed.

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