Introduction
Intraprocedural bleeding is a source of technical complexity during endoscopic submucosal dissection (ESD) and may require exchange to coagulation forceps. Spray coagulation is a non-contact, high–peak–voltage mode that combines tissue dissection with powerful coagulation. However, evidence supporting its use in ESD is limited to the stomach.
Aims & Methods
We aimed to evaluate whether spray-coagulation ESD (SP-ESD) improves intraprocedural bleeding control compared to swift ESD (SW-ESD). We analyzed consecutive esophageal, gastric, colonic, and rectal ESDs performed at a tertiary referral center over thirty-six months. SP-ESD was compared to SW-ESD. Assessment of complete procedural video was performed with event-level timestamps. SW-ESD procedures were matched 1:2 to SP-ESD procedures by propensity score on prespecified baseline covariates. The primary outcome was intraprocedural bleeding events. Secondary outcomes were total bleeding time, dissection speed, and coagulation forceps use.
Results
Of 147 eligible ESDs, 91 (60 SP-ESD, 31 SW-ESD) were matched. SP-ESD was associated with fewer bleeding events (mean 1.8 vs 4.2 per procedure; count ratio, .43; 95% CI, .26-.70; P = .001), persisting after accounting for dissection time (rate ratio, .51 per minute; 95% CI, .31-.85). Bleeding time was shorter (median .4 vs 5.5 minutes; ratio of means, .40; 95% CI, .22-.73) and dissection faster (median 16.8 vs 11.6 mm2/min; geometric mean ratio, 1.33; 95% CI, 1.03-1.70). Coagulation forceps were applied a mean of .1 versus 2.6 times per procedure, and 95.0% versus 29.0% were forceps-free (RR, 3.27; 95% CI, 1.79-5.99). R0 resection, en bloc resection, perforation, and delayed bleeding did not differ.
TABLE. Primary and secondary outcomes in the propensity score–matched cohort (n = 91)
| Outcome | SW-ESD | SP-ESD | Effect (SP-ESD vs SW-ESD, 95% CI) | P value |
| Intraprocedural bleeds, mean (primary) | 4.2 | 1.8 | CR, .43 (.26-.70) | .001 |
| Bleeding time, min, median | 5.5 | .4 | Ratio of means, .40 (.22-.73) | .003 |
| Dissection speed, mm2/min, median | 11.6 | 16.8 | GMR, 1.33 (1.03-1.70) | .027 |
Conclusion
SP-ESD was associated with substantially less intraprocedural bleeding and coagulation forceps use, and faster dissection without cost in resection quality or safety compared to SW-ESD. Spray coagulation mode can be selected as one of the available electrosurgical modalities to improve bleeding control during ESD.