Any tissue damage to the muscle layer may result in delayed bleeding or perforation, especially in the case of the thin gut wall. Enough mucosal lifting is necessary to perform ESD safely, especially where the gut wall is thinner. The walls of the esophagus and colon are thinner than that of the stomach. Thus, SH is suitable for injection in the esophagus and colon. For the stomach, SH is desirable, especially in the upper third of the stomach, whereas Glyceol, which is a hypertonic solution that causes less tissue damage, might be permissible throughout.

Submucosal fibrosis, which usually results from inflammation or tumor invasion, makes it more difficult to lift tumor tissue from the muscle layer. This in turn lengthens procedure time, creating a greater risk for complications such as perforation, and reduces the success rate of complete en bloc resection. Submucosal injection with NS may not achieve adequate lifting in cases with submucosal fibrosis; however, SH may be a good choice in cases with submucosal fibrosis because it does not cause tissue damage, and because of its high viscosity it has the ability to maintain submucosal lifting.

A relationship between complete resection and the experience of the endoscopist has been reported [6]. Even less experienced endoscopists could achieve a high rate of complete resection using SH injection for EMR, similar to skilled endoscopists. It takes a long time for less experienced endoscopists to perform ESD. When using a short-lasting injection solution, it is necessary to work fast after submucosal injection or to inject frequently in order to complete ESD. SH is effective for maintaining a long duration of mucosal elevation. Thus, less-experienced endoscopists should use SH for ESD, as this facilitates sustained mucosal elevation and definitive en bloc resection and prevents perforation.