Risk management to prevent perforation during endoscopic submucosal dissection

En bloc resection is beneficial for accurate histological assessment of resected specimens of endoscopic mucosal resection. Conventional endoscopic mucosal resection is simple and convenient but with this procedure the size of specimen obtained from one-piece resection is very limited. Endoscopic submucosal dissection (ESD) using IT knife, Hook knife, Flex knife and so on has already been reported and it is useful to some expert endoscopists, but sometimes difficult for general endoscopists to use safely. The drawback of ESD is that it is difficult and is consequently associated with a higher rate of perforation, which may reach up to 2-6%. In addition, ESD requires advanced endoscopic techniques. Further improvement of devices and techniques is expected to be developed to prevent perforation for ESD procedure.