Before starting any endoscopical procedure, in particular an endoscopic submucosal dissection, a proper and extensive evaluation of the lesion must be accomplished.

After the lesion limits are clearly identified, marking is made with a ball tip shaped knife applying soft coagulation to the mucosa. It should be performed 2-3 mm away from the lesion to provide a safety margin.

An osmotic agent is injected in the submucosal space outside the lesion margins. We prefer using a Voluven based solution with indigo carmine and adrenaline, because it lasts more than saline but is less expensive than sodium hyaluronate.

Our group supports a complete circumferential mucotomy before starting the submucosal dissection.

Submucosal dissection is carried out using the traction provided with the distal attachment. In this particular location, the dissection combines retroflex and forward view scope positions to achieve an en-bloc resection.

Once the dissection is completed, the resected specimen can be retrieved with a Roth net and then extended to allow proper pathological assessment and subsequently determine the curative role of the procedure.

A thorough evaluation of the ulcer is performed to detect muscle layer defects that may require clipping or vessels which should be coagulated.