Spray vs Forced Coagulation in ESD for Early Gastric Neoplasms

The comparison between Spray Coagulation Mode (SCM) and Forced Coagulation Mode (FCM) in Endoscopic Submucosal Dissection (ESD) for early gastric neoplasms has been thoroughly investigated in a multicenter randomized controlled trial conducted across five Japanese institutions. Below is a detailed summary of the findings:

### 1. **Primary Challenge in ESD**

• Intraoperative bleeding is a major technical challenge during ESD for early gastric neoplasms, often requiring the use of hemostatic forceps.

### 2. **Study Objective**

• The trial aimed to compare the hemostatic effectiveness of SCM-ESD and FCM-ESD in controlling bleeding during ESD.

### 3. **Study Design**

• The study was a prospective, multicenter, randomized controlled trial with balanced randomization (1:1). Stratification was based on tumor location, size, and antithrombotic use to ensure validity and generalizability.

### 4. **Key Findings**

#### a. **Knife-Only Completion Rate**

• SCM-ESD achieved a significantly higher rate of successful ESD completion using only the knife without the need for hemostatic forceps compared to FCM-ESD.

#### b. **Reduced Dependence on Hemostatic Forceps**

• SCM-ESD markedly decreased both the number and duration of hemostatic forceps use, streamlining the procedure and reducing interruptions.

#### c. **Improved Hemostasis**

• Spray coagulation provided broader and more stable coagulation, which enhanced bleeding control during submucosal dissection.

#### d. **Procedure Time and Dissection Speed**

• Despite better bleeding control, the total procedure time and submucosal dissection speed were similar between SCM-ESD and FCM-ESD groups.

#### e. **Oncologic Outcomes**

• Both groups achieved high rates of en-bloc resection (removal of the tumor in a single piece) and complete (R0) resection, with no significant differences observed.
• Curative resection rates were also comparable, indicating that SCM-ESD did not compromise oncologic efficacy.

#### f. **Injection Volume**

• SCM-ESD required significantly less submucosal injection volume compared to FCM-ESD, which may contribute to procedural efficiency and cost reduction.

#### g. **Safety Profile**

• Adverse event rates, including intraoperative bleeding and perforation, were low and comparable between the two groups.
• SCM-ESD did not increase thermal damage, ensuring that pathological margin assessments were not impaired.

#### h. **Benefit for Nonexperts**

• SCM-ESD demonstrated improved hemostasis outcomes even when performed by less experienced endoscopists, highlighting its potential to benefit a wider range of practitioners.

#### i. **Antithrombotic Use**

• The benefits of SCM-ESD were less pronounced in patients receiving antithrombotic agents, suggesting that caution is needed in this subgroup.

#### j. **Workflow Efficiency**

• SCM-ESD simplified the workflow by reducing the need for device exchanges, thereby minimizing procedural interruptions and enhancing efficiency.

### 5. **Clinical Implications**

• SCM-ESD is a promising technique for ESD in early gastric neoplasms, offering several advantages:
• Improved bleeding control.
• Reduced dependence on hemostatic forceps.
• Streamlined workflow and reduced procedural costs.
• Preservation of safety and oncologic efficacy.
• These benefits make SCM-ESD particularly appealing for less experienced endoscopists and in settings where procedural efficiency is a priority.

### 6. **Limitations**

• The benefits of SCM-ESD were less pronounced in patients on antithrombotic therapy, which may require additional strategies for optimal bleeding control in this subgroup.

### 7. **Conclusion**

• Spray coagulation mode (SCM) represents a significant advancement in ESD for early gastric neoplasms, addressing the challenge of intraoperative bleeding while maintaining safety, efficacy, and efficiency. It is a valuable technique for improving outcomes and simplifying the procedure for both expert and nonexpert endoscopists.