Endoscopic submucosal dissection for early gastric adenocarcinoma: basic procedures and management of complications

Mastery of endoscopic submucosal dissection (ESD) requires a deep understanding of not only the technique but also the preparation, electrosurgical unit, its peripherals, and probable procedural complications. An endoscope with a water-jet function is suitable for gastric ESD. A transparent attachment on the tip of the endoscope is necessary. The mucosal preparation is important for proper lesion recognition and precise device movement during the procedure and to reduce the risk of complications. A needle-type knife allows accurate tissue dissection and is especially useful for dissecting fibrosis in the submucosa. A partially insulated-type knife prevents current transmission from the tip of the needle to the deep tissues, thus reducing the risk of unintentional perforation or bleeding. When using a scissor-type knife, stable device movement is possible and unintended tissue dissection is minimized. The electrosurgical unit mode must be adjusted according to the different tissue conditions. The basic techniques for ESD incision and dissection should be mastered, and the appropriate knives, accessories, strategy, and traction device should be methodically selected by each operator. The main complications of ESD are bleeding and perforation, which should be treated appropriately when they occur.