Post written by Takafumi Maruyama, MD, Takashi Murakami, MD, PhD, Yoichi Akazawa, MD, PhD, Tomoyoshi Shibuya, MD, PhD, and Akihito Nagahara, MD, PhD, from the Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan.

Here, we present a case of improved visibility with gel immersion in the presence of ongoing bleeding during colorectal endoscopic submucosal dissection (ESD). We performed ESD for a nongranular-type laterally spreading tumor, measuring 40 mm in diameter, at the descending colon. Stable submucosal dissection for mild fibrosis beneath the lesion could be performed. However, large vessels were injured accidentally during this procedure. We attempted hemostasis with forceps, but the bleeding points were not visible because of rapid blood collection. Continuous water injection enabled transient visualization, although water and blood mixed immediately, leading to insufficient visualization. After continuous gel injection, we could identify multiple bleeding points. After each bleeding point was grasped with forceps, we applied electrocoagulation using bipolar electrocoagulation devices and achieved hemostasis. Finally, after hemostasis, the lesion was resected using an en bloc with no adverse events.

During ESD, it is often difficult to secure a visual field in the presence of ongoing massive bleeding because water rapidly mixes with fresh blood in the lumen. Gel immersion is safe and effective for securing the visual field, creating a space for endoscopic visualization and treatment in patients with ongoing bleeding.

Gel immersion endoscopy may ease hemostasis during colorectal ESD and should be considered as an endoscopic treatment option in the colorectum. To our knowledge, this is the first report of improved visibility with gel immersion in the presence of ongoing bleeding during colorectal ESD.

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