Clinical Endoscopy

The Korean Society of Gastrointestinal Endoscopy (대한소화기내시경학회)
권호 표지
DOI QR코드

DOI QR Code

Complications of endoscopic resection in the upper gastrointestinal tract

  • Received : 2023.01.04
  • Accepted : 2023.03.10
  • Published : 2023.07.30
Download PDF
⟨ Previous Next ⟩

Abstract

Endoscopic resection (ER) is widely utilized as a minimally invasive treatment for upper gastrointestinal tumors; however, complications could occur during and after the procedure. Post-ER mucosal defect leads to delayed perforation and bleeding; therefore, endoscopic closure methods (endoscopic hand-suturing, the endoloop and endoclip closure method, and over-the-scope clip method) and tissue shielding methods (polyglycolic acid sheets and fibrin glue) are developed to prevent these complications. During duodenal ER, complete closure of the mucosal defect significantly reduces delayed bleeding and should be performed. An extensive mucosal defect that comprises three-quarters of the circumference in the esophagus, gastric antrum, or cardia is a significant risk factor for post-ER stricture. Steroid therapy is considered the first-line option for the prevention of esophageal stricture, but its efficacy for gastric stricture remains unclear. Methods for the prevention and management of ER-related complications in the esophagus, stomach, and duodenum differ according to the organ; therefore, endoscopists should be familiar with ways of preventing and managing organ-specific complications.

Keywords

References

  1. Yamashina T, Ishihara R, Nagai K, et al. Long-term outcome and metastatic risk after endoscopic resection of superficial esophageal squamous cell carcinoma. Am J Gastroenterol 2013;108:544-551.  https://doi.org/10.1038/ajg.2013.8
  2. Tanabe S, Ishido K, Matsumoto T, et al. Long-term outcomes of endoscopic submucosal dissection for early gastric cancer: a multicenter collaborative study. Gastric Cancer 2017;20(Suppl 1):45-52.  https://doi.org/10.1007/s10120-016-0664-7
  3. Berger A, Rahmi G, Perrod G, et al. Long-term follow-up after endoscopic resection for superficial esophageal squamous cell carcinoma: a multicenter Western study. Endoscopy 2019;51:298-306.  https://doi.org/10.1055/a-0732-5317
  4. Yeh JH, Huang RY, Lee CT, et al. Long-term outcomes of endoscopic submucosal dissection and comparison to surgery for superficial esophageal squamous cancer: a systematic review and meta-analysis. Therap Adv Gastroenterol 2020;13:1756284820964316. 
  5. Abdelfatah MM, Barakat M, Ahmad D, et al. Long-term outcomes of endoscopic submucosal dissection versus surgery in early gastric cancer: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2019;31:418-424.  https://doi.org/10.1097/MEG.0000000000001352
  6. Nonaka S, Oda I, Tada K, et al. Clinical outcome of endoscopic resection for nonampullary duodenal tumors. Endoscopy 2015;47:129-135.  https://doi.org/10.1055/s-0034-1390774
  7. Suzuki H, Ono H, Hirasawa T, et al. Long-term survival after endoscopic resection for gastric cancer: real-world evidence from a multicenter prospective cohort. Clin Gastroenterol Hepatol 2023;21:307-318.  https://doi.org/10.1016/j.cgh.2022.07.029
  8. Oyama T, Tomori A, Hotta K, et al. Endoscopic submucosal dissection of early esophageal cancer. Clin Gastroenterol Hepatol 2005;3(7 Suppl 1):S67-S70.  https://doi.org/10.1016/S1542-3565(05)00291-0
  9. Ishihara R, Iishi H, Uedo N, et al. Comparison of EMR and endoscopic submucosal dissection for en bloc resection of early esophageal cancers in Japan. Gastrointest Endosc 2008;68:1066-1072.  https://doi.org/10.1016/j.gie.2008.03.1114
  10. Oka S, Tanaka S, Kaneko I, et al. Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer. Gastrointest Endosc 2006;64:877-883.  https://doi.org/10.1016/j.gie.2006.03.932
  11. Park YM, Cho E, Kang HY, et al. The effectiveness and safety of endoscopic submucosal dissection compared with endoscopic mucosal resection for early gastric cancer: a systematic review and metaanalysis. Surg Endosc 2011;25:2666-2677.  https://doi.org/10.1007/s00464-011-1627-z
  12. Nakamoto S, Sakai Y, Kasanuki J, et al. Indications for the use of endoscopic mucosal resection for early gastric cancer in Japan: a comparative study with endoscopic submucosal dissection. Endoscopy 2009;41:746-750.  https://doi.org/10.1055/s-0029-1215010
  13. Lian J, Chen S, Zhang Y, et al. A meta-analysis of endoscopic submucosal dissection and EMR for early gastric cancer. Gastrointest Endosc 2012;76:763-770.  https://doi.org/10.1016/j.gie.2012.06.014
  14. Cao Y, Liao C, Tan A, et al. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract. Endoscopy 2009;41:751-757.  https://doi.org/10.1055/s-0029-1215053
  15. Suzuki H, Takizawa K, Hirasawa T, et al. Short-term outcomes of multicenter prospective cohort study of gastric endoscopic resection: 'real-world evidence' in Japan. Dig Endosc 2019;31:30-39.  https://doi.org/10.1111/den.13246
  16. Ishihara R, Arima M, Iizuka T, et al. Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer. Dig Endosc 2020;32:452-493.  https://doi.org/10.1111/den.13654
  17. Guo HM, Zhang XQ, Chen M, et al. Endoscopic submucosal dissection vs endoscopic mucosal resection for superficial esophageal cancer. World J Gastroenterol 2014;20:5540-5547.  https://doi.org/10.3748/wjg.v20.i18.5540
  18. Furue Y, Katada C, Tanabe S, et al. Effectiveness and safety of endoscopic aspiration mucosectomy and endoscopic submucosal dissection in patients with superficial esophageal squamous-cell carcinoma. Surg Endosc 2019;33:1433-1440.  https://doi.org/10.1007/s00464-018-6418-3
  19. Fujishiro M, Yahagi N, Kakushima N, et al. Endoscopic submucosal dissection of esophageal squamous cell neoplasms. Clin Gastroenterol Hepatol 2006;4:688-694.  https://doi.org/10.1016/j.cgh.2006.03.024
  20. Takahashi H, Arimura Y, Masao H, et al. Endoscopic submucosal dissection is superior to conventional endoscopic resection as a curative treatment for early squamous cell carcinoma of the esophagus (with video). Gastrointest Endosc 2010;72:255-264.  https://doi.org/10.1016/j.gie.2010.02.040
  21. Teoh AY, Chiu PW, Yu Ngo DK, et al. Outcomes of endoscopic submucosal dissection versus endoscopic mucosal resection in management of superficial squamous esophageal neoplasms outside Japan. J Clin Gastroenterol 2010;44:e190-e194.  https://doi.org/10.1097/MCG.0b013e3181ce52fb
  22. Tsujii Y, Nishida T, Nishiyama O, et al. Clinical outcomes of endoscopic submucosal dissection for superficial esophageal neoplasms: a multicenter retrospective cohort study. Endoscopy 2015;47:775-783.  https://doi.org/10.1055/s-0034-1391844
  23. Odagiri H, Yasunaga H, Matsui H, et al. Hospital volume and adverse events following esophageal endoscopic submucosal dissection in Japan. Endoscopy 2017;49:321-326.  https://doi.org/10.1055/s-0042-122189
  24. Koyama Y, Abe S, Itoi T. Extensive perforation of the esophagus caused by a localized muscle layer defect during endoscopic submucosal dissection. Dig Endosc 2022;34:e40-e41.  https://doi.org/10.1111/den.14216
  25. Abe S, Wu SY, Ego M, et al. Efficacy of current traction techniques for endoscopic submucosal dissection. Gut Liver 2020;14:673-684.  https://doi.org/10.5009/gnl19266
  26. Yoshida M, Takizawa K, Nonaka S, et al. Conventional versus traction-assisted endoscopic submucosal dissection for large esophageal cancers: a multicenter, randomized controlled trial (with video). Gastrointest Endosc 2020;91:55-65.  https://doi.org/10.1016/j.gie.2019.08.014
  27. Yamamoto Y, Kikuchi D, Nagami Y, et al. Management of adverse events related to endoscopic resection of upper gastrointestinal neoplasms: review of the literature and recommendations from experts. Dig Endosc 2019;31 Suppl 1:4-20.  https://doi.org/10.1111/den.13388
  28. Lee JH, Kedia P, Stavropoulos SN, et al. AGA clinical practice update on endoscopic management of perforations in gastrointestinal tract: expert review. Clin Gastroenterol Hepatol 2021;19:2252-2261.  https://doi.org/10.1016/j.cgh.2021.06.045
  29. Takahashi R, Yoshio T, Horiuchi Y, et al. Endoscopic tissue shielding for esophageal perforation caused by endoscopic resection. Clin J Gastroenterol 2017;10:214-219.  https://doi.org/10.1007/s12328-017-0738-z
  30. Seehawong U, Morita Y, Nakano Y, et al. Successful treatment of an esophageal perforation that occurred during endoscopic submucosal dissection for esophageal cancer using polyglycolic acid sheets and fibrin glue. Clin J Gastroenterol 2019;12:29-33.  https://doi.org/10.1007/s12328-018-0900-2
  31. Omae M, Konradsson M, Baldaque-Silva F. Delayed perforation after endoscopic submucosal dissection treated successfully by temporary stent placement. Clin J Gastroenterol 2018;11:118-122.  https://doi.org/10.1007/s12328-017-0808-2
  32. Matsuda Y, Kataoka N, Yamaguchi T, et al. Delayed esophageal perforation occurring with endoscopic submucosal dissection: a report of two cases. World J Gastrointest Surg 2015;7:123-127.  https://doi.org/10.4240/wjgs.v7.i7.123
  33. Urabe Y, Hiyama T, Tanaka S, et al. Advantages of endoscopic submucosal dissection versus endoscopic oblique aspiration mucosectomy for superficial esophageal tumors. J Gastroenterol Hepatol 2011;26:275-280.  https://doi.org/10.1111/j.1440-1746.2010.06503.x
  34. Shi Q, Ju H, Yao LQ, et al. Risk factors for postoperative stricture after endoscopic submucosal dissection for superficial esophageal carcinoma. Endoscopy 2014;46:640-644.  https://doi.org/10.1055/s-0034-1365648
  35. Katada C, Muto M, Manabe T, et al. Esophageal stenosis after endoscopic mucosal resection of superficial esophageal lesions. Gastrointest Endosc 2003;57:165-169.  https://doi.org/10.1067/mge.2003.73
  36. Ono S, Fujishiro M, Niimi K, et al. Predictors of postoperative stricture after esophageal endoscopic submucosal dissection for superficial squamous cell neoplasms. Endoscopy 2009;41:661-665.  https://doi.org/10.1055/s-0029-1214867
  37. Wen J, Lu Z, Yang Y, et al. Preventing stricture formation by covered esophageal stent placement after endoscopic submucosal dissection for early esophageal cancer. Dig Dis Sci 2014;59:658-663.  https://doi.org/10.1007/s10620-013-2958-5
  38. Hanaoka N, Ishihara R, Takeuchi Y, et al. Intralesional steroid injection to prevent stricture after endoscopic submucosal dissection for esophageal cancer: a controlled prospective study. Endoscopy 2012;44:1007-1011.  https://doi.org/10.1055/s-0032-1310107
  39. Yamaguchi N, Isomoto H, Nakayama T, et al. Usefulness of oral prednisolone in the treatment of esophageal stricture after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma. Gastrointest Endosc 2011;73:1115-1121.  https://doi.org/10.1016/j.gie.2011.02.005
  40. Tanaka M, Ono H, Takizawa K. A randomized controlled phase III trial comparing oral prednisolone administration and local triamcinolone injection therapy for the prevention of esophageal stricture after endoscopic submucosal dissection, JCOG 1217 (Abstract). United European Gastroenterol J 2022;10(suppl 8):9-184.  https://doi.org/10.1002/ueg2.12293
  41. Chu Y, Chen T, Li H, et al. Long-term efficacy and safety of intralesional steroid injection plus oral steroid administration in preventing stricture after endoscopic submucosal dissection for esophageal epithelial neoplasms. Surg Endosc 2019;33:1244-1251.  https://doi.org/10.1007/s00464-018-6404-9
  42. Sakaguchi Y, Tsuji Y, Shinozaki T, et al. Steroid injection and polyglycolic acid shielding to prevent stricture after esophageal endoscopic submucosal dissection: a retrospective comparative analysis (with video). Gastrointest Endosc 2020;92:1176-1186.  https://doi.org/10.1016/j.gie.2020.04.070
  43. Ohki T, Yamato M, Ota M, et al. Prevention of esophageal stricture after endoscopic submucosal dissection using tissue-engineered cell sheets. Gastroenterology 2012;143:582-588.  https://doi.org/10.1053/j.gastro.2012.04.050
  44. Ohki T, Yamato M, Ota M, et al. Application of regenerative medical technology using tissue-engineered cell sheets for endoscopic submucosal dissection of esophageal neoplasms. Dig Endosc 2015;27:182-188.  https://doi.org/10.1111/den.12354
  45. Ezoe Y, Muto M, Horimatsu T, et al. Efficacy of preventive endoscopic balloon dilation for esophageal stricture after endoscopic resection. J Clin Gastroenterol 2011;45:222-227.  https://doi.org/10.1097/MCG.0b013e3181f39f4e
  46. Nonaka K, Miyazawa M, Ban S, et al. Different healing process of esophageal large mucosal defects by endoscopic mucosal dissection between with and without steroid injection in an animal model. BMC Gastroenterol 2013;13:72. 
  47. Kadota T, Yano T, Kato T, et al. Prophylactic steroid administration for strictures after endoscopic resection of large superficial esophageal squamous cell carcinoma. Endosc Int Open 2016;4:E1267-E1274.  https://doi.org/10.1055/s-0042-118291
  48. Sakaguchi Y, Tsuji Y, Fujishiro M, et al. Triamcinolone injection and shielding with polyglycolic acid sheets and fibrin glue for postoperative stricture prevention after esophageal endoscopic resection: a pilot study. Am J Gastroenterol 2016;111:581-583.  https://doi.org/10.1038/ajg.2016.60
  49. Sakaguchi Y, Tsuji Y, Ono S, et al. Polyglycolic acid sheets with fibrin glue can prevent esophageal stricture after endoscopic submucosal dissection. Endoscopy 2015;47:336-340.  https://doi.org/10.1055/s-0034-1390787
  50. Yoda Y, Yano T, Kaneko K, et al. Endoscopic balloon dilatation for benign fibrotic strictures after curative nonsurgical treatment for esophageal cancer. Surg Endosc 2012;26:2877-2883.  https://doi.org/10.1007/s00464-012-2273-9
  51. Takahashi H, Arimura Y, Okahara S, et al. Risk of perforation during dilation for esophageal strictures after endoscopic resection in patients with early squamous cell carcinoma. Endoscopy 2011;43:184-189.  https://doi.org/10.1055/s-0030-1256109
  52. Kishida Y, Kakushima N, Kawata N, et al. Complications of endoscopic dilation for esophageal stenosis after endoscopic submucosal dissection of superficial esophageal cancer. Surg Endosc 2015;29:2953-2959.  https://doi.org/10.1007/s00464-014-4028-2
  53. Tsujii Y, Hayashi Y, Kawai N, et al. Risk of perforation in balloon dilation associated with steroid injection for preventing esophageal stricture after endoscopic submucosal dissection. Endosc Int Open 2017;5:E573-E579.  https://doi.org/10.1055/s-0043-110077
  54. Muto M, Ezoe Y, Yano T, et al. Usefulness of endoscopic radial incision and cutting method for refractory esophagogastric anastomotic stricture (with video). Gastrointest Endosc 2012;75:965-972.  https://doi.org/10.1016/j.gie.2012.01.012
  55. Ono H, Yao K, Fujishiro M, et al. Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer (second edition). Dig Endosc 2021;33:4-20.  https://doi.org/10.1111/den.13883
  56. Ikehara H, Gotoda T, Ono H, et al. Gastric perforation during endoscopic resection for gastric carcinoma and the risk of peritoneal dissemination. Br J Surg 2007;94:992-995.  https://doi.org/10.1002/bjs.5636
  57. Minami S, Gotoda T, Ono H, et al. Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video). Gastrointest Endosc 2006;63:596-601.  https://doi.org/10.1016/j.gie.2005.07.029
  58. Abe S, Oda I, Mori G, et al. Complete endoscopic closure of a large gastric defect with endoloop and endoclips after complex endoscopic submucosal dissection. Endoscopy 2015;47 Suppl 1 UCTN:E374-E375.  https://doi.org/10.1055/s-0034-1392594
  59. Kobara H, Mori H, Nishiyama N, et al. Over-the-scope clip system: a review of 1517 cases over 9 years. J Gastroenterol Hepatol 2019;34:22-30.  https://doi.org/10.1111/jgh.14402
  60. Nagami Y, Shiba M, Arakawa T. Use of PGA sheets in the endoscopic closure of a perforation after endoscopic submucosal dissection for gastric-tube cancer. Am J Gastroenterol 2016;111:768. 
  61. Jeong JY, Oh YH, Yu YH, et al. Does submucosal fibrosis affect the results of endoscopic submucosal dissection of early gastric tumors? Gastrointest Endosc 2012;76:59-66.  https://doi.org/10.1016/j.gie.2012.03.172
  62. Ohta T, Ishihara R, Uedo N, et al. Factors predicting perforation during endoscopic submucosal dissection for gastric cancer. Gastrointest Endosc 2012;75:1159-1165.  https://doi.org/10.1016/j.gie.2012.02.015
  63. Yoshida M, Takizawa K, Suzuki S, et al. Conventional versus traction-assisted endoscopic submucosal dissection for gastric neoplasms: a multicenter, randomized controlled trial (with video). Gastrointest Endosc 2018;87:1231-1240.  https://doi.org/10.1016/j.gie.2017.11.031
  64. Suzuki H, Oda I, Sekiguchi M, et al. Management and associated factors of delayed perforation after gastric endoscopic submucosal dissection. World J Gastroenterol 2015;21:12635-12643.  https://doi.org/10.3748/wjg.v21.i44.12635
  65. Hanaoka N, Uedo N, Ishihara R, et al. Clinical features and outcomes of delayed perforation after endoscopic submucosal dissection for early gastric cancer. Endoscopy 2010;42:1112-1115.  https://doi.org/10.1055/s-0030-1255932
  66. Kang SH, Lee K, Lee HW, et al. Delayed perforation occurring after endoscopic submucosal dissection for early gastric cancer. Clin Endosc 2015;48:251-255.  https://doi.org/10.5946/ce.2015.48.3.251
  67. Ono H, Takizawa K, Kakushima N, et al. Application of polyglycolic acid sheets for delayed perforation after endoscopic submucosal dissection of early gastric cancer. Endoscopy 2015;47 Suppl 1 UCTN:E18-E19.  https://doi.org/10.1055/s-0034-1390730
  68. Ikezawa K, Michida T, Iwahashi K, et al. Delayed perforation occurring after endoscopic submucosal dissection for early gastric cancer. Gastric Cancer 2012;15:111-114.  https://doi.org/10.1007/s10120-011-0089-2
  69. Takizawa K, Oda I, Gotoda T, et al. Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection: an analysis of risk factors. Endoscopy 2008;40:179-183.  https://doi.org/10.1055/s-2007-995530
  70. Uedo N, Takeuchi Y, Yamada T, et al. Effect of a proton pump inhibitor or an H2-receptor antagonist on prevention of bleeding from ulcer after endoscopic submucosal dissection of early gastric cancer: a prospective randomized controlled trial. Am J Gastroenterol 2007;102:1610-1616.  https://doi.org/10.1111/j.1572-0241.2007.01197.x
  71. Yang Z, Wu Q, Liu Z, et al. Proton pump inhibitors versus histamine-2-receptor antagonists for the management of iatrogenic gastric ulcer after endoscopic mucosal resection or endoscopic submucosal dissection: a meta-analysis of randomized trials. Digestion 2011;84:315-320.  https://doi.org/10.1159/000331138
  72. Zullo A, Manta R, De Francesco V, et al. Endoscopic submucosal dissection of gastric neoplastic lesions in Western countries: systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2021;33:e1-e6.  https://doi.org/10.1097/MEG.0000000000001886
  73. Ngamruengphong S, Ferri L, Aihara H, et al. Efficacy of endoscopic submucosal dissection for superficial gastric neoplasia in a large cohort in North America. Clin Gastroenterol Hepatol 2021;19:1611-1619.  https://doi.org/10.1016/j.cgh.2020.06.023
  74. Libanio D, Costa MN, Pimentel-Nunes P, et al. Risk factors for bleeding after gastric endoscopic submucosal dissection: a systematic review and meta-analysis. Gastrointest Endosc 2016;84:572-586.  https://doi.org/10.1016/j.gie.2016.06.033
  75. Hatta W, Tsuji Y, Yoshio T, et al. Prediction model of bleeding after endoscopic submucosal dissection for early gastric cancer: BEST-J score. Gut 2021;70:476-484.  https://doi.org/10.1136/gutjnl-2019-319926
  76. Fujimoto K, Fujishiro M, Kato M, et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. Dig Endosc 2014;26:1-14.  https://doi.org/10.1111/den.12183
  77. Mochizuki S, Uedo N, Oda I, et al. Scheduled second-look endoscopy is not recommended after endoscopic submucosal dissection for gastric neoplasms (the SAFE trial): a multicentre prospective randomised controlled non-inferiority trial. Gut 2015;64:397-405.  https://doi.org/10.1136/gutjnl-2014-307552
  78. Ryu HY, Kim JW, Kim HS, et al. Second-look endoscopy is not associated with better clinical outcomes after gastric endoscopic submucosal dissection: a prospective, randomized, clinical trial analyzed on an as-treated basis. Gastrointest Endosc 2013;78:285-294.  https://doi.org/10.1016/j.gie.2013.02.008
  79. Kim JS, Chung MW, Chung CY, et al. The need for second-look endoscopy to prevent delayed bleeding after endoscopic submucosal dissection for gastric neoplasms: a prospective randomized trial. Gut Liver 2014;8:480-486.  https://doi.org/10.5009/gnl13226
  80. Uozumi T, Sumiyoshi T, Tomita Y, et al. Does second-look endoscopy reduce the bleeding after gastric endoscopic submucosal dissection for patients receiving antithrombotic therapy? BMC Cancer 2021;21:946. 
  81. Kataoka Y, Tsuji Y, Hirasawa K, et al. Endoscopic tissue shielding to prevent bleeding after endoscopic submucosal dissection: a prospective multicenter randomized controlled trial. Endoscopy 2019;51:619-627.  https://doi.org/10.1055/a-0860-5280
  82. Kawata N, Ono H, Takizawa K, et al. Efficacy of polyglycolic acid sheets and fibrin glue for prevention of bleeding after gastric endoscopic submucosal dissection in patients under continued antithrombotic agents. Gastric Cancer 2018;21:696-702.  https://doi.org/10.1007/s10120-018-0791-4
  83. Ego M, Abe S, Nonaka S, et al. Endoscopic closure utilizing endoloop and endoclips after gastric endoscopic submucosal dissection for patients on antithrombotic therapy. Dig Dis Sci 2021;66:2336-2344.  https://doi.org/10.1007/s10620-020-06508-8
  84. Maekawa S, Nomura R, Murase T, et al. Complete closure of artificial gastric ulcer after endoscopic submucosal dissection by combined use of a single over-the-scope clip and through-the-scope clips (with videos). Surg Endosc 2015;29:500-504.  https://doi.org/10.1007/s00464-014-3725-1
  85. Akimoto T, Goto O, Sasaki M, et al. Endoscopic hand suturing for mucosal defect closure after gastric endoscopic submucosal dissection may reduce the risk of postoperative bleeding in patients receiving antithrombotic therapy. Dig Endosc 2022;34:123-132.  https://doi.org/10.1111/den.14045
  86. Goto O, Oyama T, Ono H, et al. Endoscopic hand-suturing is feasible, safe, and may reduce bleeding risk after gastric endoscopic submucosal dissection: a multicenter pilot study (with video). Gastrointest Endosc 2020;91:1195-1202.  https://doi.org/10.1016/j.gie.2019.12.046
  87. Jung DH, Moon HS, Park CH, et al. Polysaccharide hemostatic powder to prevent bleeding after endoscopic submucosal dissection in high risk patients: a randomized controlled trial. Endoscopy 2021;53:994-1002.  https://doi.org/10.1055/a-1312-9420
  88. Hahn KY, Park JC, Lee YK, et al. Efficacy of hemostatic powder in preventing bleeding after gastric endoscopic submucosal dissection in high-risk patients. J Gastroenterol Hepatol 2018;33:656-663.  https://doi.org/10.1111/jgh.13990
  89. Prei JC, Barmeyer C, Burgel N, et al. EndoClot polysaccharide hemostatic system in nonvariceal gastrointestinal bleeding: results of a prospective multicenter observational pilot study. J Clin Gastroenterol 2016;50:e95-e100.  https://doi.org/10.1097/MCG.0000000000000615
  90. Tsunada S, Ogata S, Mannen K, et al. Case series of endoscopic balloon dilation to treat a stricture caused by circumferential resection of the gastric antrum by endoscopic submucosal dissection. Gastrointest Endosc 2008;67:979-983.  https://doi.org/10.1016/j.gie.2007.12.023
  91. Coda S, Oda I, Gotoda T, et al. Risk factors for cardiac and pyloric stenosis after endoscopic submucosal dissection, and efficacy of endoscopic balloon dilation treatment. Endoscopy 2009;41:421-426.  https://doi.org/10.1055/s-0029-1214642
  92. Iizuka H, Kakizaki S, Sohara N, et al. Stricture after endoscopic submucosal dissection for early gastric cancers and adenomas. Dig Endosc 2010;22:282-288.  https://doi.org/10.1111/j.1443-1661.2010.01008.x
  93. Kakushima N, Tanaka M, Sawai H, et al. Gastric obstruction after endoscopic submucosal dissection. United European Gastroenterol J 2013;1:184-190.  https://doi.org/10.1177/2050640613490288
  94. Sumiyoshi T, Kondo H, Minagawa T, et al. Risk factors and management for gastric stenosis after endoscopic submucosal dissection for gastric epithelial neoplasm. Gastric Cancer 2017;20:690-698.  https://doi.org/10.1007/s10120-016-0673-6
  95. Kishida Y, Kakushima N, Takizawa K, et al. Effects of steroid use for stenosis prevention after wide endoscopic submucosal dissection for gastric neoplasm. Surg Endosc 2018;32:751-759.  https://doi.org/10.1007/s00464-017-5732-5
  96. Yoshida M, Yabuuchi Y, Kakushima N, et al. The incidence of non-ampullary duodenal cancer in Japan: the first analysis of a national cancer registry. J Gastroenterol Hepatol 2021;36:1216-1221.  https://doi.org/10.1111/jgh.15285
  97. Goda K, Kikuchi D, Yamamoto Y, et al. Endoscopic diagnosis of superficial non-ampullary duodenal epithelial tumors in Japan: multicenter case series. Dig Endosc 2014;26 Suppl 2:23-29.  https://doi.org/10.1111/den.12277
  98. Yamasaki Y, Uedo N, Akamatsu T, et al. Nonrecurrence rate of underwater EMR for ≤20-mm nonampullary duodenal adenomas: a multicenter prospective study (D-UEMR Study). Clin Gastroenterol Hepatol 2022;20:1010-1018.  https://doi.org/10.1016/j.cgh.2021.06.043
  99. Kiguchi Y, Kato M, Nakayama A, et al. Feasibility study comparing underwater endoscopic mucosal resection and conventional endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumor < 20 mm. Dig Endosc 2020;32:753-760.  https://doi.org/10.1111/den.13524
  100. Yamasaki Y, Uedo N, Takeuchi Y, et al. Underwater endoscopic mucosal resection for superficial nonampullary duodenal adenomas. Endoscopy 2018;50:154-158.  https://doi.org/10.1055/s-0043-119214
  101. Maruoka D, Arai M, Ishigami H, et al. Cold polypectomy for nonampullary duodenal adenoma. Endoscopy 2015;47 Suppl 1 UCTN:E477-E478.  https://doi.org/10.1055/s-0034-1392668
  102. Hamada K, Takeuchi Y, Ishikawa H, et al. Safety of cold snare polypectomy for duodenal adenomas in familial adenomatous polyposis: a prospective exploratory study. Endoscopy 2018;50:511-517.  https://doi.org/10.1055/s-0043-124765
  103. Kato M, Takeuchi Y, Hoteya S, et al. Outcomes of endoscopic resection for superficial duodenal tumors: 10 years' experience in 18 Japanese high volume centers. Endoscopy 2022;54:663-670.  https://doi.org/10.1055/a-1640-3236
  104. Kuroki K, Sanomura Y, Oka S, et al. Clinical outcomes of endoscopic resection for superficial non-ampullary duodenal tumors. Endosc Int Open 2020;8:E354-E359.  https://doi.org/10.1055/a-0998-3708
  105. Yahagi N, Kato M, Ochiai Y, et al. Outcomes of endoscopic resection for superficial duodenal epithelial neoplasia. Gastrointest Endosc 2018;88:676-682.  https://doi.org/10.1016/j.gie.2018.05.002
  106. Fukuhara S, Kato M, Iwasaki E, et al. Management of perforation related to endoscopic submucosal dissection for superficial duodenal epithelial tumors. Gastrointest Endosc 2020;91:1129-1137.  https://doi.org/10.1016/j.gie.2019.09.024
  107. Tsutsumi K, Kato M, Kakushima N, et al. Efficacy of endoscopic preventive procedures to reduce delayed adverse events after endoscopic resection of superficial nonampullary duodenal epithelial tumors: a meta-analysis of observational comparative trials. Gastrointest Endosc 2021;93:367-374.  https://doi.org/10.1016/j.gie.2020.08.017
  108. Mizutani M, Kato M, Sasaki M, et al. Predictors of technical difficulty for complete closure of mucosal defects after duodenal endoscopic resection. Gastrointest Endosc 2021;94:786-794.  https://doi.org/10.1016/j.gie.2021.04.017
  109. Yahagi N, Nishizawa T, Akimoto T, et al. New endoscopic suturing method: string clip suturing method. Gastrointest Endosc 2016;84:1064-1065.  https://doi.org/10.1016/j.gie.2016.05.054
  110. Ye LP, Mao XL, Zheng HH, et al. Safety of endoscopic resection for duodenal subepithelial lesions with wound closure using clips and an endoloop: an analysis of 68 cases. Surg Endosc 2017;31:1070-1077.  https://doi.org/10.1007/s00464-016-5065-9
  111. Mori H, Shintaro F, Kobara H, et al. Successful closing of duodenal ulcer after endoscopic submucosal dissection with over-the-scope clip to prevent delayed perforation. Dig Endosc 2013;25:459-461.  https://doi.org/10.1111/j.1443-1661.2012.01363.x
  112. Doyama H, Tominaga K, Yoshida N, et al. Endoscopic tissue shielding with polyglycolic acid sheets, fibrin glue and clips to prevent delayed perforation after duodenal endoscopic resection. Dig Endosc 2014;26 Suppl 2:41-45.  https://doi.org/10.1111/den.12253
  113. Takimoto K, Imai Y, Matsuyama K. Endoscopic tissue shielding method with polyglycolic acid sheets and fibrin glue to prevent delayed perforation after duodenal endoscopic submucosal dissection. Dig Endosc 2014;26 Suppl 2:46-49.  https://doi.org/10.1111/den.12280
  114. Fukuhara S, Kato M, Iwasaki E, et al. External drainage of bile and pancreatic juice after endoscopic submucosal dissection for duodenal neoplasm: feasibility study (with video). Dig Endosc 2021;33:977-984.  https://doi.org/10.1111/den.13907
  115. Abe H, Hatta W, Ogata Y, et al. Prevention of delayed bleeding with vonoprazan in upper gastrointestinal endoscopic treatment. J Gastroenterol 2021;56:640-650. https://doi.org/10.1007/s00535-021-01781-4