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Prophylactic underwater vessel coagulation for submucosal endoscopy
  1. Antonio Capogreco1,
  2. Cesare Hassan1,2,
  3. Federico De Blasio1,
  4. Davide Massimi1,
  5. Roberto de Sire1,
  6. Piera Alessia Galtieri1,
  7. Edward John Despott3,
  8. Asma Alkandari4,
  9. Pradeep Bhandari5,
  10. Antonio Facciorusso6,
  11. Roberta Maselli1,2,
  12. Alessandro Repici1,2
  1. 1 Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Lombardia, Italy
  2. 2 Department of Biomedical Sciences, Humanitas University, Milan, Italy
  3. 3 Royal Free Unit for Endoscopy, Centre for Gastroenterology, Royal Free Hospital, London, UK
  4. 4 Thanyan Alghanim Gastroenterolgy and Hepatology Center, Amiri Hospital, Kuwait City, Kuwait
  5. 5 Department of Gastroenterology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
  6. 6 Department of Medical Sciences, Section of Gastroenterology, Università degli Studi di Foggia, Foggia, Puglia, Italy
  1. Correspondence to Dr Antonio Capogreco, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Lombardia, Italy; antonio.capogreco{at}

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Submucosal endoscopy procedures including myotomy and endoresections using dissection knives can be hampered by intraprocedural bleeding, which negatively affects feasibility and procedural time. Large vessels usually require precutting coagulation with a dedicated coagulation forceps before subsequent dissection requiring frequent device exchanges between knives and coagulation forceps. Using saline immersion, vessels can be sealed with the tip of the electrosurgical knife and a special electrocautery setting. In 21 patients undergoing peroral endoscopy myotomy, there was no instrument exchange necessary as opposed to a 27% rate in a historical control group. The presealing coagulation resulted in a 21% reduction of intraprocedural bleeding that required retreatment with either dissection knife or coagulation forceps.

In more detail

One of the major procedural risks of third space endoscopy techniques is represented by intraprocedural bleeding.1 A clear strategy to reduce the risk of intraprocedural bleeding remains elusive, since current guidelines do not suggest a standardised approach, and existing practice consists of the direct coagulation of the designed vessels during submucosal dissection.2 Bleeding episodes can lengthen or complicate these procedures, by obstructing clear visualisation of the structures or resulting in the application of excessive electrocoagulation current.3 In some of these cases, complete haemostasis is not achievable, and the use of additional haemostatic devices, such as coagulation forceps, is required. However, these forceps present with some limitations, requiring the exchange of the device, slowing procedures and increasing the costs. In addition, by applying soft coagulation current, it may result in an unpredictable risk of deep mural injuries.4

As shown in figure 1, during the third space endoscopy submucosal dissection phase performed under CO2 …

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  • Contributors AC, AR, RM and CH designed the study. AC, AR, CH, FDB and RdS wrote the manuscript. AC, FDB and AF performed statistical analysis. All authors recruited patients, performed endoscopic procedures and/or participated in the data collection. All authors revised and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests AC is a consultant for ERBE. RM is a consultant for ERBE, Fujifilm, 3DMatrix and Boston Scientific. CH is a consultant for Alpha-Sigma, Fujifilm, Medtronic, Norgine, Olympus and Pentax. AR is a consultant for Medtronic, ERBE, Fujifilm and Olympus. Others authors have nothing to declare.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.