Popularity of endoscopic submucosal dissection (ESD) has shown an increase during the last decade, and may, for the time being, be the most important technique in treatment of early gastrointestinal cancer or a premalignant lesion. This technique has advantages in the aspect of en bloc resection, which enables evaluation of the completeness of resection and other pathologic characteristics; however, it has limitation in terms of complications, compared to endoscopic mucosal resection (EMR). Bleeding and perforation are the most common complications encountered during the procedure. These complications can cause embarrassment for the endoscopist and hamper performance of the procedure, which can result in an incomplete resection. To overcome these obstacles during performance of the procedure, we should be familiar with management of complications. In particular, beginners who start performing ESD should have full knowledge of and be in good handling of the method of hemostasis using hemoclips or electrocoagulation for management of complications. Various methods, procedures, and equipment are under development, which will provide us with powerful tools for achievement of successful ESD without complications in the near future. 1. Introduction ESD (endoscopic submucosal dissection) is widely used as a treatment for early cancerous and premalignant lesions in the gastrointestinal tract. When compared with the conventional EMR (endoscopic mucosal resection) method, ESD presents various advantages, such as a higher degree of complete resection and en bloc resection; however, it is also associated with a higher potential for complications, such as perforation or bleeding [1–3]. This chapter examines bleeding and perforation, which are complications that can occur during ESD, and investigates measures for dealing with such complications. 2. Management of Bleeding Immediate bleeding was defined as bleeding that occurred during the ESD procedure. The degree of bleeding has not been validated yet; however, a recent study presented the grading system as follows: grade 0 (no visible bleeding during procedure), grade 1 (trivial bleeding which stops spontaneously or easily controlled by single session of hemocoagulation), grade 2 (minor bleeding which controlled by multiple sessions of hemocoagulation or easily controlled by hemoclips), and grade 3 (major bleeding which needs multiple hemoclips and hemocoagulation) [4]. Delayed bleeding was generally defined as one of the following: hematemesis or melena, unstable vital signs or hemoglobulin loss >2？g/dl after the
References
[1]
M. Fujishiro, N. Yahagi, N. Kakushima et al., “Successful nonsurgical management of perforation complicating endoscopic submucosal dissection of gastrointestinal epithelial neoplasms,” Endoscopy, vol. 38, no. 10, pp. 1001–1006, 2006.
[2]
S. Oka, S. Tanaka, I. Kaneko et al., “Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer,” Gastrointestinal Endoscopy, vol. 64, no. 6, pp. 877–883, 2006.
[3]
R. Soetikno, T. Kaltenbach, R. Yeh, and T. Gotoda, “Endoscopic mucosal resection for early cancers of the upper gastrointestinal tract,” Journal of Clinical Oncology, vol. 23, no. 20, pp. 4490–4498, 2005.
[4]
S. W. Jeon, M. K. Jung, C. M. Cho et al., “Predictors of immediate bleeding during endoscopic submucosal dissection in gastric lesions,” Surgical Endoscopy and Other Interventional Techniques, vol. 23, no. 9, pp. 1974–1979, 2009.
[5]
I. K. Chung, J. H. Lee, S. H. Lee et al., “Therapeutic outcomes in 1000 cases of endoscopic submucosal dissection for early gastric neoplasms: Korean ESD Study Group multicenter study,” Gastrointestinal Endoscopy, vol. 69, no. 7, pp. 1228–1235, 2009.
[6]
K. Takizawa, I. Oda, T. Gotoda et al., “Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection—an analysis of risk factors,” Endoscopy, vol. 40, no. 3, pp. 179–183, 2008.
[7]
O. Goto, M. Fujishiro, S. Kodashima et al., “A second-look endoscopy after endoscopic submucosal dissection for gastric epithelial neoplasm may be unnecessary: a retrospective analysis of postendoscopic submucosal dissection bleeding,” Gastrointestinal Endoscopy, vol. 71, no. 2, pp. 241–248, 2010.
[8]
D. A. Elphick and D. P. Hurlstone, “Should routine coagulation of visible vessels be performed after endoscopic submucosal dissection,” Nature Clinical Practice Gastroenterology and Hepatology, vol. 5, no. 10, pp. 544–545, 2008.
[9]
S. Seewald and N. Soehendra, “Perforation: part and parcel of endoscopic resection?” Gastrointestinal Endoscopy, vol. 63, no. 4, pp. 602–605, 2006.
[10]
K. Mannen, S. Tsunada, M. Hara et al., “Risk factors for complications of endoscopic submucosal dissection in gastric tumors: analysis of 478 lesions,” Journal of Gastroenterology, vol. 45, no. 1, pp. 30–36, 2010.
[11]
S. W. Jeon, M. K. Jung, S. K. Kim et al., “Clinical outcomes for perforations during endoscopic submucosal dissection in patients with gastric lesions,” Surgical Endoscopy and Other Interventional Techniques, vol. 24, no. 4, pp. 911–916, 2010.
[12]
S. Minami, T. Gotoda, H. Ono, I. Oda, and H. Hamanaka, “Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video),” Gastrointestinal Endoscopy, vol. 63, no. 4, pp. 596–601, 2006.
[13]
G. Jeong, J. H. Lee, M. K. Yu et al., “Non-surgical management of microperforation induced by EMR of the stomach,” Digestive and Liver Disease, vol. 38, no. 8, pp. 605–608, 2006.
[14]
M. Bittinger and H. Messmann, “Is nonsurgical management safe and effective for patients with microperforation caused by EMR? Commentary,” Nature Clinical Practice Gastroenterology and Hepatology, vol. 4, no. 3, pp. 134–135, 2007.
[15]
S. Coda, I. Oda, T. Gotoda, C. Yokoi, T. Kikuchi, and H. Ono, “Risk factors for cardiac and pyloric stenosis after endoscopic submucosal dissection, and efficacy of endoscopic balloon dilation treatment,” Endoscopy, vol. 41, no. 5, pp. 421–426, 2009.
