Endoscopic submucosal dissection (ESD) is reported to be an efficient treatment with a high rate of en bloc resection for large colorectal tumors in Japan and some other Western and Asian countries. ESD is considered less invasive than laparoscopic colectomy. However, ESD carries a higher risk of perforation than endoscopic mucosal resection (EMR). Various devices and training methods for colorectal ESD have been developed to solve the difficulties. In this review, we describe the complications of colorectal ESD and prevention of those complications. On the other hand, colorectal ESD is difficult for less-experienced endoscopists. The unique step-by-step ESD training system is performed in Japan. Additionally, appropriate training, including animal model training, for colorectal ESD should be acquired before working on clinical cases. 1. Introduction Endoscopic submucosal dissection (ESD) is reported to be an efficient treatment with a high rate of en bloc resection for large colorectal tumors in Japan and some other Western and Asian countries. The rate of en bloc resection for large colorectal tumors by ESD was reported to be 80–98.9% [1–9]. ESD is considered less invasive than laparoscopic colectomy. However, ESD carries a higher risk of perforation than endoscopic mucosal resection (EMR) [7, 8] owing to its associated technical difficulties. First, the colon is winding in nature and has many folds. Moreover, the wall of the colon is thinner than the gastric wall. Various devices and training methods for colorectal ESD have been developed to solve the difficulties. In this review, we describe the complications of colorectal ESD, prevention of those complications, and training for the procedure. 2. Safe and Efficient Strategy and Our Therapeutic Results The following are the steps in our routine ESD procedure (Figure 1) [3, 7, 8]. First, injection for submucosal elevation is performed with a 25G needle (8B27A; TOP, Tokyo, Japan) after visualization of the border of the tumor, and mucosal incisions are made. A partial circumferential incision is made on the distal side of the tumor. If the tumor is >50？mm in size, the incision is performed at the proximal side of the tumor because in large tumors, it is sometimes difficult to resect the residual mucosa on the proximal side in the presence of a partially resected tumor. Mucosal incisions are performed with the endocut mode (endocut I, effect 2, duration 2, interval 1 in VIO300D; Erbe Elektromedizin Ltd., Tubingen, Germany). Then, simultaneously, an incision into the deep submucosa is made. After the
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