Surgical Endoscopy

, Volume 32, Issue 12, pp 5031–5036 | Cite as

“Underwater” endoscopic submucosal dissection: a novel method for resection in saline with a bipolar needle knife for colorectal epithelial neoplasia

  • Shunsuke Yoshii
  • Tomofumi Akasaka
  • Yoshito Hayashi
  • Yoshiki Tsujii
  • Kengo Nagai
  • Koji Higashino
  • Ryu Ishihara
  • Hideki Iijima
  • Tetsuo TakeharaEmail author
Dynamic Manuscript



Despite improvements in therapeutic strategy and instrumentation in colorectal endoscopic submucosal dissection (ESD), adverse events sometimes occur. Further advancements in available techniques are required to improve procedural success rates and safety. We developed a novel method for ESD in saline, referred to as “underwater” ESD (UESD). UESD involves using a bipolar needle knife and aims to enable complete resection while minimizing thermal damage to the muscle layer. In this study, we evaluated the safety and efficacy of this new technique.


This was a retrospective study using data from two referral centers and included 40 lesions diagnosed as colorectal epithelial neoplasia (> 20 mm in diameter or with severe fibrosis) and treated with UESD between December 2015 and March 2017. The main outcome measures were technical success rate, incidence of adverse events, and feasibility of histologic evaluation of the resected specimens.


All 40 lesions, including those with submucosal fibrosis, underwent successful en bloc resection using the UESD technique. No procedural adverse events including perforation, delayed bleeding, and electrocoagulation syndrome were observed, and all patients had an uneventful clinical course associated with UESD. In all cases, UESD provided a resected specimen adequate for histological evaluation, without unwarranted burn effect to the tissues.


Our UESD technique was safe and effective for complete resection of colorectal epithelial neoplasia.


Endoscopic submucosal dissection Colorectal cancer Underwater 


Compliance with ethical standards


Drs. Shunsuke Yoshii, Tomofumi Akasaka, Yoshito Hayashi, Yoshiki Tsujii, Kengo Nagai, Koji Higashino, Ryu Ishihara, Hideki Iijima, and Tetsuo Takehara have no conflicts of interest or financial ties to disclose.

Supplementary material

Video 1. “Underwater” endoscopic submucosal dissection (UESD) procedure for a rectal laterally spreading tumor of granular type, and management of active bleeding underwater (MPG 70394 KB)

Video 2. “Underwater” endoscopic submucosal dissection (UESD) procedure for colorectal epithelial neoplasia in patients with submucosal fibrosis (MPG 37673 KB)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Shunsuke Yoshii
    • 1
  • Tomofumi Akasaka
    • 2
  • Yoshito Hayashi
    • 1
  • Yoshiki Tsujii
    • 1
  • Kengo Nagai
    • 1
  • Koji Higashino
    • 2
  • Ryu Ishihara
    • 2
  • Hideki Iijima
    • 1
  • Tetsuo Takehara
    • 1
    Email author
  1. 1.Department of Gastroenterology and HepatologyOsaka University Graduate School of MedicineOsakaJapan
  2. 2.Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan

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