Spray coagulation mode provides a powerful non-contact coagulative effect that may facilitate bleeding control and increase the efficiency of endoscopic submucosal dissection (ESD).¹ However, evidence supporting its use is limited. We aimed to compare bleeding control, safety and technical outcomes between spray-coagulation ESD (SP-ESD) and swift-coagulation ESD (SW-ESD).

We conducted a retrospective cohort study of consecutive ESDs performed at a tertiary referral center between December 2021 and December 2024. Two predefined time-based cohorts were analysed using complete procedural video review: SW-ESD and SP-ESD. Procedures with mixed energy modes or incomplete video/data were excluded. ESDs were performed by experts and fellows using various techniques (conventional, pocket-creation method, traction, saline-immersion).

Primary outcomes were: number of intraprocedural bleedings, bleeding time (duration of intraprocedural bleeding), dissection speed (mm²/min), effective dissection rate (1 − [bleeding time/dissection duration]), ESD completion without coagulation forceps, and intraprocedural perforation.

Secondary outcomes included R0 resection rate and adverse events (delayed bleeding, delayed perforation).

We employed non-parametric tests and evaluated covariate imbalance between groups to ensure comparability.

141 ESDs (SP-ESD: n=114; SW-ESD: n=27) were included, performed in the oesophagus (52/141, 36.9%), stomach (16, 11.3%), duodenum (2, 1.4%), colon (39, 27.7%), and rectum (32, 22.7%). Baseline patient, lesion, and operator characteristics were similar between groups.

The mean number of intraprocedural bleeding events (2.2 ± 4.1 vs. 4.4 ± 2.6; P = 0.007) and median bleeding time (0.6 min, IQR 0–3.7 vs. 5.8 min, IQR 1.4–11.8; P < 0.001) were significantly lower in SP-ESD than in SW-ESD.

The median dissection speed (16.8 mm²/min, IQR 12.2 vs. 11.2 mm²/min, IQR 9.2; P = 0.003), effective dissection rate (99.3% vs. 95.5%; P = 0.001), and rate of ESD completion without coagulation forceps (95% vs. 26%; P < 0.001) were significantly higher in SP-ESD compared with SW-ESD.

SP-ESD and SW-ESD did not differ significantly in delayed perforation (0.8% vs. 0%; P = 1.00), delayed bleeding (6.7% vs. 3.7%; P = 1.00), or R0 resection rates (85% vs. 81%; P = 0.77).

Spray coagulation during ESD significantly reduces both the frequency and duration of intraprocedural bleeding, resulting in faster dissection, fewer device exchanges, and improved procedural efficiency without compromising safety or the completeness of resection. SP-ESD may also reduce the environmental and financial footprint of ESD by lowering the need for coagulation forceps.  Given the possibility of confounding from learning curve effects, prospective multicenter validation is warranted.