AGA Institute Clinical Practice Update: Endoscopic Submucosal Dissection in the United States  Peter V. Draganov, Andrew Y. Wang, Mohamed O. Othman, Norio Fukami  Clinical Gastroenterology and Hepatology  Volume 17, Issue 1, Pages 16-25.e1 (January 2019) DOI: 10.1016/j.cgh.2018.07.041 Copyright © 2019 AGA Institute Terms and Conditions

Figure 1 Importance of post-ESD specimen management for accurate histopathologic assessment. (A) Placing EMR specimens in formalin without pinning the specimen results in curled edges and distortion of the muscularis mucosae. (B) ESD specimens should be affixed to a flat surface with pins before tissue fixation, which results in a proper specimen orientation with straight edges and a nondistorted muscularis mucosae layer. Clinical Gastroenterology and Hepatology 2019 17, 16-25.e1DOI: (10.1016/j.cgh.2018.07.041) Copyright © 2019 AGA Institute Terms and Conditions

Supplementary Figure 1 Gastric ESD assisted by using endoscopic traction. A 79-year-old Korean man was referred for ESD of a 4-cm, Paris 0–IIa+IIc lesion with high-grade dysplasia arising from a background of gastric intestinal metaplasia that was located in the incisura and involved the lesser curve of the stomach. The lesion had been biopsied by the referring physician and tattooed. (A) Narrow-band imaging (Olympus America, Center Valley, PA) showed an irregular vascular pattern with amorphous areas suggestive of high-grade dysplasia. Superficial ulcerations corresponded to areas previously sampled with cold forceps biopsies. (B) The borders of the lesion were marked, which is required for gastric ESD because the borders can become indistinct after submucosal injection. Additional peripheral marks can be added to pathologically orient the specimen after resection. Six percent hetastarch in 0.9% sodium chloride tinted with methylene blue was injected dynamically to lift the lesion. (C) ESD was begun from the distal margin using a DualKnife (Olympus America). (D) Because of submucosal fibrosis from the prior tattoo and biopsies, 1 endoclip tied with dental floss was affixed to the distal lip of the partially resected lesion and a second endoclip was used to hold the thread against the opposite gastric wall to provide (E) pulley-type traction. (F) ESD was completed, and fibrotic tattooed submucosa was seen along the left side of the resection base. (G) En bloc resection was achieved and the specimen was pinned to expanded white polystyrene foam. Pathology showed multifocal high-grade dysplasia, but no invasive cancer. (H) Follow-up endoscopy 3 months later showed a healed scar with some residual inflammation on NBI, and surveillance biopsies confirmed no residual dysplasia. Clinical Gastroenterology and Hepatology 2019 17, 16-25.e1DOI: (10.1016/j.cgh.2018.07.041) Copyright © 2019 AGA Institute Terms and Conditions