Efficacy of a gel injected using an endoscopic water jet for visualization of active bleeding during esophageal endoscopic submucosal dissection

Active bleeding often occurs during esophageal endoscopic submucosal dissection (ESD), making it difficult to identify the bleeding point. During esophageal ESD, bleeding on the left wall of the esophagus is often difficult to visualize because of the difficulty of the patient’s changing position. We report a new method using a gel product to secure the visual field of esophageal ESD when hemostasis is difficult.

We show the application of this method in a real case of active bleeding during ESD ([Video 1]). The present case was an 80-year-old man who underwent ESD for early esophageal cancer. The 15-mm flat lesion was located on the left wall of the lower esophagus ([Fig. 1]). Active hemorrhage occurred during dissection on the left wall side of the lesion ([Fig. 2]). First we injected distilled water using an endoscopic water jet (GIF-H290T; Olympus Medical Systems, Co., Tokyo, Japan) to secure the field of view, but the blood spread quickly and we could not secure an adequate field of view. Subsequently, 200 ml of a 25 % aluminum chloride gel (Visco Clear; Otsuka Pharmaceutical Factory, Inc., Tokushima, Japan) was injected using an endoscopic water jet [1] [2] [3]. The gel remained in the esophagus long enough to allow easy visualization and pinpoint hemostasis despite the active bleeding ([Fig. 3]). After pinpoint hemostasis was achieved, ESD was completed without complications ([Fig. 4]). The gel product was transparent and had sufficient viscosity, and suppressed the diffusion and flow of blood. In addition, the gel product was less viscous than lubricating jellies and could be easily injected into the esophagus using the endoscopic water jet. This method of injecting gel using an endoscope with a water-jet function can easily identify the active bleeding point during esophageal ESD, minimizing the risk of complications [4].

Video 1 The application of an injected gel product for a real case of active bleeding during esophageal endoscopic submucosal dissection.

Fig. 1 Endoscopic submucosal dissection (ESD) was performed for early esophageal cancer.

Fig. 2 Active hemorrhage occurred during dissection on the left wall side of the lesion.

Fig. 3 The gel product helped to easily identify the active bleeding point.

Fig. 4 ESD was completed without complications.

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Competing interests

The author, Hidekazu Suzuki, has received service honoraria from AstraZeneca K.K., Astellas, Co., Daiichi-Sankyo Co., Otsuka Pharmaceutical Co. Ltd., Otsuka Pharmaceutical Factory, Inc. and Takeda Pharmaceutical Co. Ltd. and is the recipient of research grants from Daiichi-Sankyo Co., MSD Co., Otsuka Pharmaceutical Co. Ltd., Takeda Pharm. Co., Tanabe-Mistubishi Pharm. Co. and Tsumura Co. The author, Masaya Sano, has received service honoraria from Otsuka Pharmaceutical Factory, Inc. and Takeda Pharmaceutical Co. Ltd. The other authors declare that they have no conflict of interest.

• References

• 1 Yano T, Nemoto D, Ono K. et al. Gel immersion endoscopy: a novel method to secure the visual field during endoscopy in bleeding patients (with videos). Gastrointest Endosc 2016; 83: 809-811
• 2 Maruyama T, Murakami T, Akazawa Y. et al. A case of improved visibility with gel immersion in the presence of ongoing bleeding during colorectal endoscopic submucosal dissection. VideoGIE 2021; 6: 478-480
• 3 Sekiguchi H, Yano T, Tokoro S. et al. Low-pressure endoscopy using the gel immersion method facilitates endoscopic variceal ligation of ruptured esophageal varices. Endoscopy 2021;
• 4 Khurelbaatar T, Miura Y, Yano T. et al. Electrolyte-free gel immersion endoscopic submucosal dissection of gastric lesions. Endoscopy 2021;

Publication History

Article published online:
25 August 2022