ERBE VIO Settings for Endoscopic Submucosal Dissection (ESD) in the Stomach

Ustawienia ERBE VIO dla poszczególnych etapów ESD żołądka

The American Gastroenterological Association recommends using the Endocut Q mode with settings: effect 2-3, duration 1, interval 3, to ensure controlled cutting with minimal coagulation 1
The American Gastroenterological Association suggests using the Drycut mode, effect 5, 60W, to ensure effective cutting with adequate hemostasis 1
The American Gastroenterological Association recommends using the Soft Coag mode, effect 5, 80W, for coagulation with the knife tip 1

Patients should be on a liquid diet for at least 24 hours before the procedure, as recommended by the American Gastroenterological Association 2
The American Gastroenterological Association recommends using antibiotic prophylaxis effective against intestinal pathogens before the procedure 2
The procedure should be performed under general anesthesia, in the supine or left lateral position, as recommended by the American Gastroenterological Association 2
A high-resolution gastroscope with a water jet function and a transparent hood is required, as recommended by the American Gastroenterological Association 2
Low-flow CO2 insufflation (avoiding air completely) is necessary, as recommended by the American Gastroenterological Association 2, 3

The use of dyes such as indigo carmine or methylene blue is recommended to stain the submucosal fibers, but not the muscularis propria, facilitating orientation in the safe submucosal plane, as recommended by the American Gastroenterological Association 3
In cases of deep resection, the unstained muscularis propria will contrast with the blue-stained submucosa, as recommended by the American Gastroenterological Association 3
Large vascular complexes found in the submucosal tunnel may require the use of hemostatic clips to ensure thermal coagulation at low voltage before cutting, as recommended by the American Gastroenterological Association 2

Patients are often hospitalized overnight for observation after ESD, as recommended by the American Gastroenterological Association 2
If no adverse events occur, patients can start a liquid diet, as recommended by the American Gastroenterological Association 2
Patients with significant abdominal pain, tachycardia, and/or fever after the procedure should undergo computed tomography or upper gastrointestinal series, as recommended by the American Gastroenterological Association 2

The European Society of Gastrointestinal Endoscopy recommends using the Endocut Q mode with effect 2-3, duration 1, and interval 3 for incision of the mucosa, and the Drycut mode with effect 5, 60W for submucosal dissection 4
For larger lesions in the stomach, it may be necessary to increase the power 5, 6

The European Society of Gastrointestinal Endoscopy recommends avoiding prolonged use of pure coagulation current due to increased risk of delayed bleeding and thermal tissue damage 7, 8, 9, 10, 5
The use of blended or automatic (Endocut) current is a safer option for diathermy, as it provides adequate cutting properties combined with effective hemostasis 7, 8, 9, 10, 5
Studies on pig models have shown less tissue damage depth when using blended current compared to pure coagulation (p=0.0157) 8, 9, 10, 5

The American Gastroenterological Association recommends standard ESD technique in the antrum, which includes making a full circumferential incision that isolates the lesion with a 3-4 mm margin of normal mucosa 11
After the initial incision, an additional submucosal injection is recommended to facilitate dissection 11
A full circumferential incision allows for better control of dissection and increases the chances of en bloc resection 11

The standard solution for ESD consists of physiological saline (isotonic NaCl solution) and a dye - indigocarmine, which is prepared by mixing 15 ml of physiological saline with 5 ml of 0.8% indigocarmine solution to obtain a 0.2% final solution 12, 13
To achieve a 0.2% indigocarmine solution, 5 ml of 0.8% indigocarmine solution should be mixed with 15 ml of sterile water or physiological saline 13
The solution should be prepared immediately before the procedure to ensure its sterility 12

The solution is injected into the submucosal layer using a needle introduced through an endoscope, causing the lesion to be lifted and facilitating its resection 12
Indigocarmine accumulates in the mucosal depressions, highlighting the borders of the lesion and facilitating the assessment of its morphology 13

Besides physiological saline with indigocarmine, other solutions can be used, such as:
- Hydroxyethylcellulose (HES) - a relatively inexpensive colloid solution providing longer-lasting tissue lift 14, 15
- SIC-8000 (Eleview) - a ready-to-use preparation containing water, sodium chloride, poloxamer 188, polyoxyl-15-hydroxystearin, medium-chain triglycerides, and methyl blue 15, 16
- EverLift - containing water, glycerin, hydroxyethylcellulose, benzyl alcohol, sodium, potassium phosphate, and methyl blue 15

The solution should be injected in a way that creates a focal submucosal bleb under the entire lesion 12
For large lesions (≥20 mm), it may be necessary to use a larger volume of solution or consider using a colloid solution, which provides longer-lasting tissue lift 14, 15
The American Gastroenterological Association recommends using a solution that provides adequate visualization and lift for safe and effective ESD procedures 12