Submucosal endoscopy procedures including myotomy and endoresections using dissection knives can be hampered by intraprocedural bleeding, which negatively affects feasibility and procedural time. Large vessels usually require precutting coagulation with a dedicated coagulation forceps before subsequent dissection requiring frequent device exchanges between knives and coagulation forceps. Using saline immersion, vessels can be sealed with the tip of the electrosurgical knife and a special electrocautery setting. In 21 patients undergoing peroral endoscopy myotomy, there was no instrument exchange necessary as opposed to a 27% rate in a historical control group. The presealing coagulation resulted in a 21% reduction of intraprocedural bleeding that required retreatment with either dissection knife or coagulation forceps.

One of the major procedural risks of third space endoscopy techniques is represented by intraprocedural bleeding.1 A clear strategy to reduce the risk of intraprocedural bleeding remains elusive, since current guidelines do not suggest a standardised approach, and existing practice consists of the direct coagulation of the designed vessels during submucosal dissection.2 Bleeding episodes can lengthen or complicate these procedures, by obstructing clear visualisation of the structures or resulting in the application of excessive electrocoagulation current.3 In some of these cases, complete haemostasis is not achievable, and the use of additional haemostatic devices, such as coagulation forceps, is required. However, these forceps present with some limitations, requiring the exchange of the device, slowing procedures and increasing the costs. In addition, by applying soft coagulation current, it may result in an unpredictable risk of deep mural injuries.4

As shown in figure 1, during the third space endoscopy submucosal dissection phase performed under CO2 …