Management of bleeding is crucial for a successful endoscopic submucosal dissection (ESD) with the Flex knife for a stomach neoplasm. Medical approaches to suppress gastric acid secretion and keep systolic blood pressure at the level of < 150 mmHg during ESD are tried to lessen bleeding. But, major concerns for bleeding are whether the blood vessels are cut off or not and endoscopic surgeons have to avoid blind application of devices for ESD as much as possible. Even in the situations where blind application for non-visible vessels in the submucosa is not preventable such as in the steps of marking, submucosal injection, mucosal incision, and snaring, the efforts to lessen bleeding are necessary. When non-bleeding visible vessels are noticed, 'prebleeding coagulation' with appropriate devices is important. Even if unexpected bleeding occurs, it is also controllable using appropriate devices according to the type of bleeding. All endscopists who perform ESD should also be experts in management of bleeding.
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