So, I have prepared a small video, basically I was asked to talk about the complications of ESD, the two most common being bleeding and perforation and, you know, nothing's better than obviously demonstrating live as you've seen a few times by our demonstrators of various techniques and instruments that they're using. But we'll just go through a couple of examples, nothing formal. So, the first case is a case of a polyp we were actually sent to manage because of bleeding, a large lobulated hyperplastic looking polyp extending from the GE junction down into the stomach in a patient who was post gastric bypass. And we started the dissection, this is well into the dissection and really encountered a lot of bleeding. So, here you see a bleeding vessel and one of the first things that's important to do is to not panic. Here you see me actually place the cap on the vessel and suction and then in time to have enough time to get the coag raspers down. There you could see that, I'm just going to pause that for a second, that while I have coag raspers on what I think is the blood vessel, clearly you see it's still bleeding. And what's really important to really effectively coagulate these vessels is to accurately target the vessel so that you're bringing both sides together. So, I actually let go and I reposition and then grasp in here, I haven't even applied energy yet, but just by tamponading it, you can see it stopped. So, I know it's the right spot. And then I'm using settings of soft coag. You wait several seconds while it bubbles to really know that you've created coagulation. However, there was still a lot more bleeding and here to just to demonstrate for one second, again, using water irrigation and your cap and really being patient can actually show you the source. So, this is a split vessel where both sides actually have been open, probably one that was grabbed by the knife, but not grabbed all the way through. And that was an SB knife that we had been using in that situation. So, here again, there's a lot of clarity that comes from just irrigating in order to be able to visualize the source of your bleeding. Here, again, we use a different knife. Here's the IT knife and bleeding is starting. And just when you think, I think if you had seen throughout the procedure, I'm just going to stop that for one second. We had kind of seen those vessels open, but not bleeding. And there's some who might think that, well, if it's not actively bleeding, then you can leave it alone. But likely what happened is that pressure built up a little bit and you can see that these vessels are a couple of different vessels likely coming off of a larger vessel here. So, it's important to make sure that you actually treat any of these visible vessels. Sometimes you really just have to throw your arms up and surrender to the procedure. I would say the bleeding took up most of the time during this procedure. Now, because of the concern of other underlying vessels that could be open and the tendency for GE junction lesions to bleed, the resection beds to bleed, we decided to close this lesion. Now, this is another version of suturing. This is the X-TAC system by Apollo where you actually, the tacks are attached to sutures. You place them on all sides of the lesion. So, you're not taking a full bite through the actual mucosa. You're just screwing the tack into the mucosa and that's attached to a running suture. And then at the end, so I'm going side to side here, distal to proximal. At the end, we will cinch this just the same way you do with a regular suturing system. So, this is the fourth tack going on. And then we'll see the device, the cinching device come out. And there you see that. And then we'll cut that and we'll close this. And so, this patient did very well, had no further bleeding. I'm just going to stop for one second. No further bleeding, actually went home the next day. And that kind of a lesion is normally a patient that I would say I would keep for a minimum of a day to two days and advance their diet very slowly. In that case, I could advance much more quickly. I just want to contrast this type of bleeding management to POEM. As you saw during the procedure, in POEM, you really need to, in the ESD, you want to grab the source of the bleeding, pull it away from the muscle and coagulate. However, in POEM, sometimes you need to really get deep. So, especially in the situation of perforating vessels, where the vessel is hidden beneath the muscle layer and you have to grab not only the full thickness of the muscle itself to get to the vessel, if you can't visualize it, but sometimes even cut the muscle layer in order to expose the actual vessel so that you can adequately coagulate. There, the tissue that I grabbed was not going to stop the bleeding, so I repositioned. This is a situation of ESD where I just want to kind of highlight that it's important to really, especially in a scene where the blood has taken over and is obscuring your view of all vessels and submucosa, you really do want to localize the bleeding because there is risk for perforation in these situations, so, which you just saw there. Because of the, because of my concern for potential for perforation and the amount of bleeding I had during this procedure, I did decide to close this using clips and I could do this because the defects were close enough together. These are rotatable clips, you start from one edge, approximate the tissue and bring it together. This is another example of an ESD where I had concern here for potential perforation. Now, it's not a full through and through, there probably is some serosa down there. If this is a perforation at all, we had that discussion during the rectal case. Does this need to be closed? I chose because this was a right-sided lesion and my concern for potentially for this to become worse, I did decide to close it. Now, this is a much larger defect in which clips would be difficult to use, so I again used that X-TAC system from the oral side to the anal side, specifically over the site of the defect that I was concerned about. Now, I didn't intend to close the entire lesion using these, but at least by bringing the edges closer together, I could then follow this with a clip placement because the edges were closer together. This is an example of a perforation in the rectum by Nikhil Kumpta, this from several years ago. Here, you can see that there's a potential muscularis defect there. He continued on with the resection as we've talked about before, but in this situation, used a suturing system to specifically close that defect. In this case, he did contain the closure to within the resection bed, the defect itself. Another approach would be to close the entire defect from mucosa to mucosa using this suturing system. Next video, I've included, so this is a second suture that he replaced. Then again, this time connecting it to the mucosa to close up that portion of the defect bed and then cinching it closed. Then in this video, it's not actually an ESD, it's an EMR, but I included it more so to show another closure device. This is a full thickness defect after EMR. In this situation, the OTSC Ovesco clip was used and you have a suction in the peritoneum, so you actually have a nomental or fat closure. You can tell there's full closure here, and so that's just another device to use. Similarly, there's a padlock clip available that can do a similar type of full thickness. In general, I think for bleeding, the most important thing is to remain calm, to really be able to visualize, localize the bleeding source, and have targeted coagulation therapy to the vessels. You can use your cap to provide a little tamponade. You can use suction as I demonstrated. You can use the tip of your knife with a closed knife as Suwani demonstrated, or coagulation graspers for the actual coagulation. In the defect closure, I think the most critical thing is to not stop your procedure, really make sure that you don't have any concern for contamination of vessels, I mean of contents, and carry on as much as possible, and then plan your closure technique.

endoscopic submucosal dissection

complications

bleeding management

perforation

defect closure