fig6

Figure 6. (A) Schema of “trimming”. The trimming is performed until the surface of the muscularis propria. (B) Endoscopic image of trimming during endoscopic submucosal dissection (ESD). The muscularis propria behind the transparent submucosa is whitish. (C) After trimming and injection of solution into the submucosa, the initial submucosal plane for submucosal dissection is recognized easily. Isolation of the specimen from the normal mucosa avoids leakage of the injected solution and allows efficient mucosal lifting by submucosal injection. (D) After “trimming”, submucosal dissection at the lateral or distal part of the specimen can be easily performed. Note that the deep submucosa is less vascular and fibrous.