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Page 16 of 20 Nakamura et al. Mini-invasive Surg 2022;6:50 https://dx.doi.org/10.20517/2574-1225.2022.38

prevention of stenosis after both cardiac and pyloric ESD, administering oral steroids was more effective
than the injection of steroids, and a combination of intralesional steroid injection and oral steroids did not
seem to increase the preventive effect on stenosis [82,86,89] .

Stenosis after gastric ESD is primarily treated by EBD. Two articles reported that there was no perforation
related to EBD for cardiac stenosis [81,82] , whereas perforation that developed during EBD for pyloric stenosis
required emergency surgery [81-83,90] . There are two reports that describe the usefulness of mucosal incision of
the stenotic ulcer scar and subsequent steroid injection [88,91] .

Aspiration pneumonia
Apparent or silent pneumonia occurs in 0.62%-6.6% of patients undergoing gastric ESD [92,93] . Risk of
[94]
pneumonia is increased in elderly patients (OR: 2.52, P < 0.00001) . Other risk factors include a long
(> 2 h) procedure time and male sex . Patients with aspiration pneumonia have high body temperature,
[95]
white blood cell count, and C-reactive protein level . The plain chest X-ray shows an abnormal finding in
[92]
66.7% of patients, while a reminder was detected in the chest CT scan. Most ESD-related aspiration
pneumonia develops in the left lung. Adequate suction of the saliva during the ESD procedure may prevent
aspiration pneumonia . Aslan et al. suggested the use of an overtube reduced the need for suction during
[96]
ESD procedure, thus it may be useful as a preventive measure . The clinical course of ESD-related
[97]
aspiration pneumonia is favorable with the appropriate use of antibiotics .
[92]
CONCLUSION
The preparation, techniques, and complications of gastric ESD are outlined herein. Mastery of ESD requires
a deep understanding of not only the technique but also the electrosurgical unit, its peripherals, and
probable procedural complications. The basics of the procedure are important, yet do not require anything
special except expertise borne out of practice. Subsequently, the basic techniques for ESD incision and
dissection should be mastered, and the appropriate knives, attachments, strategy, and traction device should
be methodically selected by each operator.

DECLARATIONS
Acknowledgments
We thank Edanz Group (https://en-author-services.edanz.com/ac) for editing a draft of this manuscript.

Authors’ contributions
Drafted the article: Nakamura T
Conception and design, critical revision of the article for important intellectual content, and final approval
of the article: Uedo N

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.