Mitigating risk following upper gastrointestinal Endoscopic Submucosal Dissection: preventing bleeding, perforation...

Endoscopic submucosal dissection (ESD) is an effective organ-sparing technique for superficial neoplasia in the upper gastrointestinal tract, although it remains associated with a non-negligible risk of complications. This narrative review provides an integrated overview of the entire ESD pathway, from pre-procedural risk stratification to intraprocedural management and post-procedural care. Adverse events should be interpreted as the result of the interaction between patient-related factors, lesion characteristics, and procedural complexity. During the procedure, maintaining stable control of the submucosal plane is central; in this context, strategies such as anticipatory vessel coagulation, optimized dissection, traction, and saline immersion contribute to improve visualization and reduce bleeding and perforation risk. Post-procedural risk is largely site-specific, with stricture predominating in the esophagus, delayed bleeding in the stomach, and both bleeding and perforation in the duodenum. A risk-adapted approach is therefore essential to improve safety and optimize outcomes.