Coagulation forceps-sparing techniques for pre-emptive sealing of blood vessels during third-space endoscopy.

Background and Aims: Intraprocedural bleeding is a significant concern during third-space endoscopy, particularly in procedures like peroral endoscopic myotomy and endoscopic submucosal dissection. Although coagulation forceps can be used to effectively manage large blood vessels, their use necessitates frequent instrument exchanges, disrupting procedural flow and increasing costs. This review describes several distinct coagulation techniques to achieve coagulation without the need for hemostatic forceps. Methods: The following coagulation techniques were used: noncontact coagulation (SprayCoag E 5.5), saline immersion coagulation (SprayCoag E 5.5), contact coagulation with low-dose energy (PreciseSect E 0.9-1) or retracted tip of knife (SwiftCoag E 4), microwave coagulation using a bipolar device (10 W), and application of a novel self-assembling peptide (PuraStat). Results: All the techniques effectively coagulated the blood vessels, with a low incidence of breakthrough bleeding and need for adjunctive hemostatic techniques reported. The transition from air to saline lowers impedance, thereby reducing voltage, which in turn diminishes the dissection effect while enhancing coagulation efficiency. The dissection power of SprayCoag and other coagulation modes (SwiftCoag or PreciseSect) could be adjusted by increasing the target distance or reducing the energy dose, respectively. Use of a novel bipolar device enables coagulation using microwave energy and application of self-assembling peptide gel minimizes the need for an electrosurgical unit for coagulation. Conclusions: Several coagulation techniques effectively seal large blood vessels during submucosal dissection procedures, reducing reliance on hemostatic forceps. Further studies comparing these methods with conventional approaches are warranted to confirm their broader clinical applicability.