Enhancing safety and efficacy in gastric endocopic submucosal dissection: a commentary on continuous low-pressure saline perfusion

We have read with keen interest the article by Ino et al., titled “Continuous low-pressure saline perfusion for gastric endoscopic submucosal dissection” [1]. The report introduces a novel method that significantly improves the endoscopic visual field during ESD by employing continuous low-pressure saline perfusion.

The authors have successfully demonstrated the advantages of this technique in maintaining an unobstructed visual field and the potential cost–effectiveness of using physiological saline solution and a gastric tube. It is also noted that this method allows operators to focus solely on the high-frequency device pedal, streamlining the procedure.

However, we would like to draw your attention to the potential implications of this technique for patients under anesthesia, especially concerning the risks of aspiration and coughing. The continuous saline perfusion might heighten the risk of fluid entering the airway, potentially leading to serious complications such as aspiration pneumonia or laryngospasm in patients undergoing general anesthesia. It would be valuable if the authors could elucidate the measures implemented to pre-empt such incidents and the safety protocols established for patients undergoing this procedure.

Establishing a quantifiable threshold for “low-pressure” saline infusion that ensures a balance between visibility and patient comfort and safety is also crucial. Moreover, the immediate requirement for swift and efficient blood clearance during active bleeding episodes is a critical facet of ESD. Insights from the authors on how continuous low-pressure saline perfusion tackles this challenge and any observed complications related to blood clearance would be highly beneficial.

Lastly, the long-term outcomes and potential complications associated with continuous saline perfusion should be addressed in future studies. These should includes a detailed analysis of the risk of hypernatremia and water intoxication.

The paper is a significant contribution to the field, and we anticipate future research that builds upon these findings, particularly in the context of patient safety.

Publication History

Article published online:
22 April 2025

• Reference

• 1 Ino Y, Fukuda H, Ueno T. et al. Continuous low-pressure saline perfusion for gastric endoscopic submucosal dissection. Endoscopy 2024; 18: E880-E881