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Figure 3. (A) A 40-mm laterally spreading granular-type tumor in the ascending colon; (B) mucosal defect after endoscopic submucosal
dissection; (C) first clip with line is placed on the anal mucosa; (D) another clip is anchored to the oral side; (E) by pulling the line
through the accessory channel, the mucosa with clips come close together; (F) additional endoclips with/without a line are placed to
achieve complete closure.

Hand-suturing
Uninterrupted endoscopic suturing of the mucosal defect after colorectal ESD with an absorbable barbed
suture and a through-the-scope needle holder has been reported . Although it is technically challenging
[45]
and requires an extended procedure time (median: 56 min), further modification of the technique and
devices could lead to clinical use.

The Overstitch System is also reportedly feasible and safe . If the procedure becomes easier, widespread
[46]
use is expected.

Underwater clip closure
A higher en bloc resection rate for middle-sized polyps by underwater EMR compared to conventional EMR
[47]
has been reported . Also, following ESD, underwater conditions lead to efficient clip closure of the wound
enabling downsizing of the mucosal defect .
[48]
COUNTERMEASURES FOR COMPLICATIONS
Bleeding after ESD
Most bleeding following ESD occurs within 2 weeks of the procedure, particularly within the first 24 h. The
rate of bleeding after ESD was reported as 0.4%-4.6% [49-55] . Bleeding is usually managed by endoscopic
intervention and rarely requires transfusion or surgical intervention. Antithrombotic and anticoagulant
agents have known risk factors for bleeding, and guidelines about their management for patients
undergoing endoscopy have been published [56-61] . Currently, patients with comorbidities, and patients taking
aspirin or warfarin have increased bleeding risk . A retrospective study suggested that preventive
[62]
[63]
coagulation of visible vessels in the resection area after gastric ESD may reduce the bleeding rate .