ORIGINAL ARTICLE: Clinical Endoscopy Polyglycolic acid sheets and fibrin glue decrease the risk of bleeding after endoscopic submucosal dissection of gastric neoplasms (with video) Yosuke Tsuji, MD, PhD, 1,2 Mitsuhiro Fujishiro, MD, PhD, 1,2 Shinya Kodashima, MD, PhD, 1 Satoshi Ono, MD, PhD, 1 Keiko Niimi, MD, PhD, 3 Satoshi Mochizuki, MD, PhD, 1 Itsuko Asada-Hirayama, MD, 1 Rie Matsuda, MD, 1 Chihiro Minatsuki, MD, 1 Chiemi Nakayama, MD, 1 Yu Takahashi, MD, 1 Yoshiki Sakaguchi, MD, 1 Nobutake Yamamichi, MD, PhD, 1 Kazuhiko Koike, MD, PhD 1 Tokyo, Japan Background: The prevention of bleeding after endoscopic submucosal dissection (ESD) for gastric neoplasms is still an important problem. Objective: To investigate the efficacy and safety of a shielding method that uses polyglycolic acid (PGA) sheets and fibrin glue to prevent post-ESD bleeding in high-risk patients. Design: A nonrandomized trial with historical control subjects. Setting: A single academic hospital in Japan. Patients: From July 2013 to February 2014, 45 ESD-induced ulcers in 41 patients with a high risk of bleeding were enrolled in a study group. Forty-one consecutive ESD-induced ulcers in 37 control subjects with a high risk of bleeding were treated in 2013 before the first enrollment. Interventions: We placed PGA sheets on the mucosal defect and fixed with fibrin glue in the study group. Main Outcome Measurements: The post-ESD bleeding rate. Results: The post-ESD bleeding occurred at a rate of 6.7% in the study group (3/45 lesions) and 22.0% in the historical control group (9/41 lesions). There was a significant difference in the post-ESD bleeding rate between the 2 groups (P Z .041). Limitations: A nonrandomized trial with historical control subjects; a single-center analysis; small sample size. Conclusions: The endoscopic tissue shielding method with PGA sheets and fibrin glue appears to be promising for the prevention of post-ESD bleeding. (Clinical trial registration number: UMIN000011058.) (Gastro- intest Endosc 2015;81:906-12.) (footnotes appear on last page of article) Endoscopic submucosal dissection (ESD) has been accepted as an excellent treatment for gastric neoplasms because a large tumor or lesion with an ulcer scar can be successfully resected in an en bloc fashion. 1-4 ESD is mini- mally invasive and can be applied to elderly patients. 5 Moreover, ESD is reported to be safe and effective, even for early gastric cancer in the altered anatomy, such as a remnant stomach or gastric tube, and locally recurrent early gastric cancer after endoscopic resec- tion. 6-8 According to guidelines from the Japanese Gastric Cancer Association, 9 absolute guideline criteria for tu- mors indicated for ESD are differentiated-type mucosal adenocarcinoma % 2 cm without ulcerative findings. The indication criteria for endoscopic resection have been expanded based on the large case series treated by gastrectomy with lymph node dissection, 10 and there have been some reports about the validity of the expanded criteria. 1,11,12 The tumors categorized into expanded criteria were as follows: a differentiated-type mucosal adenocarcinoma O 2 cm without ulcerative This video can be viewed directly from the GIE website or by using the QR code and your mobile de- vice. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. 906 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 4 : 2015 www.giejournal.org