How to decrease the risk of perforation in endoscopic submucosal dissection (ESD)

Endoscopic submucosal dissection (ESD) is an accepted method for curative resection for various gastrointestinal tumors. Although ESD is effective in resecting gastrointestinal tumors, the risk of perforation is a major barrier for training and adoption of this technique. Therefore, techniques for preventing perforation during ESD should be a focus when learning ESD. The most important aspect of preventing perforation during ESD is to have solid basic therapeutic endoscopic skills. Next, extensive supervised hands-on experience in ex vivo training models is important to learn proper ESD techniques prior to performing ESD in patients. Finally, the appropriate endoscopic accessories and methods of ESD should be selected according to the specific characteristics of the lesion. The application of these principles will result in minimizing the risk of perforation while performing ESD.