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Page 12 of 20 Nakamura et al. Mini-invasive Surg 2022;6:50 https://dx.doi.org/10.20517/2574-1225.2022.38

Figure 8. Procedure for submucosal dissection with a partially insulated knife.

Traction technique
When a lesion exists at the base of gravity and natural traction cannot be obtained, the traction method is
effective in achieving a good view of the operative field during gastric ESD. Traction devices are generally
[15]
divided into two types: external and internal. External traction includes the clip-with-line method , and
internal traction includes S-O Clip and multi-loop traction devices . An RCT failed to show that the
[17]
[16]
clip-with-line method reduces procedure time significantly in all cases compared to that by conventional
ESD, although it was useful in lesions in the greater curvature and upper and middle parts of the
stomach . A single-center RCT comparing gastric ESD using an S-O clip and conventional ESD indicated
[18]
[19]
a significant reduction in procedure time in the S-O clip group . The usefulness of the traction method for
[20]
lesions with severe submucosal fibrosis is suggested in some observational studies .
ADVERSE EVENTS AND MANAGEMENT
Delayed bleeding
Gastric ESD has a risk of delayed bleeding ranging from 3.6% to 6.9% [21-27] . A retrospective observational
study indicated that prophylactic coagulation for all visible vessels at the base of post-ESD ulcers reduced
the incidence of delayed bleeding and is commonly performed as a routine practice. Several RCTs and a
meta-analysis indicated that proton pump inhibitor (PPI) administration significantly reduced the
incidence of delayed bleeding compared with the administration of histamine-2 receptor antagonists
(H2RA); thus, PPIs are recommended .
[28]

A meta-analysis identified several significant risk factors for delayed bleeding after gastric ESD including
antithrombotic drug intake, chronic kidney diseases, resected specimen size > 30 mm, and use of an H2RA
instead of a PPI . The latest large-scale retrospective cohort study identified predictors for delayed
[29]
bleeding after gastric ESD as warfarin, direct oral anticoagulant, chronic kidney disease with hemodialysis,
P2Y12 receptor antagonist, aspirin, cilostazol, tumor size > 30 mm, lower-third in tumor location, presence
[30]
of multiple tumors, and interruption of each kind of antithrombotic agents [Table 4] . The risk scoring
system developed from the cohort can stratify bleeding risk as low risk (0-1 point, 2.8%), intermediate risk
(2 points, 6.1%), high risk (3-4 points, 11.4%), and very high risk (≥ 5 points, 29.7%).