Before starting training of ESD, pre-procedural, theoretic preparation is necessary. An endoscopist who intends to learn ESD must learn not only about the technique of ESD, but also the basic knowledge of bleeding (e.g. risk factors, incidence, management, etc.), as well as apparatuses such as electrosurgical units, endoscopic knives, and various other devices. The physician should also check all information of ESD patient, such as the past medical history and daily medications, especially anticoagulant agents.

The next steps for trainees are to observe expert endoscopists in action as they perform ESD procedures and assist experts performing the procedure, before beginning themselves. By assisting experienced endoscopists, trainees acquire the skills needed to troubleshoot various situations. Moreover, obtaining expertise in hemostasis before starting ESD is highly recommended since most of the difficulties surrounding the procedure are related to uncontrollable hemorrhage [58].

An endoscope with a water jet function (GIF-Q260J, Olympus, Tokyo, Japan) mounted with a soft transparent hood (TOP Co. Ltd., Tokyo, Japan) is mainly used. This helps facilitate placement of the endoscope, especially during tumor dissection. Normal saline has been used as the injection solution for EMR; however, to achieve better lifting of the lesion in order to lessen the risk of perforation and to lessen tissue damage of the resected specimen, a solution containing sodium hyaluronate has been developed [59]. Many groups now use a commercially available solution of 0.4 % sodium hyaluronate (MucoUp, Johnson & Johnson, Tokyo, Japan). These solutions are usually combined with diluted epinephrine, which is used for the prevention of active bleeding.

Various knives can be used in ESD. At our institution, we developed IT knife-2 (KD-611L; Olympus, Tokyo, Japan). The difference between the IT knife (KD-610L; Olympus, Tokyo, Japan) and the IT knife-2 is the attachment of a short, three-prong blade between the needle and the ceramic tip (Fig. 16.1a, b). Drawbacks in cutting performance of the IT knife have been remarkably improved with the IT knife-2, such as cutting difficulty while the endoscope is looking downward and the relatively poor performance of cutting in a lateral direction. Consequently, the operating time using the IT knife-2 is reported to be much shorter than that using the original IT knife [16, 36, 60].

Since the development of IT knife-2 was mainly for application in the stomach, the insulated tip was too large to be used in the esophagus and colon where the submucosal layer is thinner and the lumen is narrower. To solve these issues, the new IT knife nano (KD-612L; Olympus, Tokyo, Japan) was recently developed, which has a smaller insulated tip (Fig. 16.1c, d). Now, the IT knife-2 is mainly used for gastric ESD, and IT knife nano for esophageal and colonic ESD.

At our institution, the VIO300D (Erbe, Germany) is mainly used as the electrosurgical unit. The instruments and settings are shown in Table 16.3. For hematemesis, we use hot biopsy forceps (Radial jaw, Boston Scientific, Tokyo, Japan) for stomach, and Coagrasper (FD-410LR, Olympus, Tokyo, Japan) (Fig. 16.2) for esophagus and colon. In cases of severe bleeding that could not be stopped by coagulation, endoclips were deployed. Because endoclips interfere with the subsequent resection procedure or dissection, one should dissect more submucosal tissue around the bleeding site in order to better expose the bleeding site before clipping.

Bleeding during the procedure is infrequent with EMR techniques, but is quite common and almost unavoidable with ESD. It sometimes requires the procedure to be withheld or aborted; however, with the development of new endoscopic techniques and technology, it now only rarely becomes significant to the extent that requires the procedure to be aborted [8]. Management of immediate bleeding plays a critical role in the successful completion of ESD.

Immediate bleeding was found in 63 of 945 patients (7 %) in a previous report, in which immediate bleeding was defined as the diminution of 2 g/dL in hemoglobin (Hb) between pre-procedure and next-day levels [8]. The rates of significant immediate bleeding in the upper and middle thirds of the stomach are higher than in the lower third (Table 16.4) because of the larger diameter of the submucosal arteries in the upper and middle thirds of the stomach [61].