Devices, techniques, traction, suturing, and countermeasures for endoscopic submucosal dissection complications

Endoscopic submucosal dissection (ESD) is widely performed to treat superficial colorectal tumors because it enables en bloc resection of various types of lesions. However, ESD sometimes leads to deleterious adverse events, such as perforation and delayed bleeding. Therefore, determining the precise preoperative indication for ESD is vitally important. Furthermore, small lesions with fibrosis and semi-large lesions can be managed using underwater endoscopic mucosal resection, and the "true" indication for ESD is for the treatment of larger lesions, for which ESD carries a higher risk. Here, we reviewed the devices, techniques (i.e., pocket creation method, water pressure method, and clip and flap method), traction (i.e., clip with line, pulley method, and clip with ring), suturing (i.e., lineassisted complete closure, loop clip, clip-on-clip closure method, mucosal incision around the mucosal defect, and hand-suturing), and countermeasures to address complications (i.e., bleeding after ESD, perforation, and post-ESD coagulation syndrome) that facilitate easier and safer ESD.