Reply to Liu & Li

Thank you for your interest and your insightful questions [1].

We perform ESD without gastric distension. The endoscopic view can be maintained through the transparent cap (ST hood) attached to the tip of the endoscope. In addition, submucosal dissection is performed in the submucosal space created by the pocket-creation method, which requires no luminal expansion. We try to keep the stomach collapsed during the procedure.

In our method of continuous low-pressure saline perfusion, the flow rate of the waterjet pump is set to the lowest. By using a nasogastric tube placed in the stomach, all of the infused saline is drained. The gastric lumen can be maintained at low pressure with slow saline flow and constant drainage. This effectively minimizes the risk of vomiting or aspiration. In addition, we believe that the risk of aspiration pneumonia is reduced when the gastric lumen is collapsed because the patient is less distressed and the procedure can be performed with light sedation. We can confirm that the gastric lumen is maintained at low pressure by observing the collapsed lumen with an endoscope.

In the event of arterial bleeding, we immediately use the transparent cap to compress the bleeding site to temporarily stop the bleeding and insert hemostatic forceps. If vision is lost in saline, we use gel immersion endoscopy [2].

Lastly, we believe the risks of hypernatremia and water intoxication are low because we use isotonic physiological saline and most of the infused saline is removed through the nasogastric tube.

We have not observed any cases of aspiration, discontinuation due to uncontrolled bleeding, hypernatremia, and water intoxication in our experience of 44 cases to date. However, it is important to confirm the safety of the procedure as you suggest. We plan to provide a summary of case outcomes in a future report.

Publication History

Article published online:
22 April 2025

• References

• 1 Liu Q, Li S. Enhancing safety and efficacy in gastric endocopic submucosal dissection: a commentary on continuous low-pressure saline perfusion. Endoscopy 2024;
• 2 Yano T, Takezawa T, Hashimoto K. et al. Gel immersion endoscopy: Innovation in securing the visual field – clinical experience with 265 consecutive procedures. Endosc Int Open 2021; 9: E1123-E1127