We Present a Case of an 80-Year-Old Male That Underwent an EGD for Evaluation of Dyspepsia

We present a case of an 80-year-old male that underwent an EGD for evaluation of dyspepsia.

A suspicious 70mm circumferential flat lesion was found involving the middle and lower esophagus. This lesion was evaluated using iodine chromoendoscopy and did not show iodine uptake. Biopsies from the lesion showed squamous cell carcinoma and a CT scan was negative for nodal and distal metastasis. After discussion of the different treatment options, the patient opted for ESD.

White lightendoscopy demonstrated a reddish rough mucosa which widely spread from middle to lower esophagus. Iodine staining revealed that this lesion involved complete luminal circumference. ESD was performed in left lateral position with monitored anesthesia care. First, ESD started with semi-circumferential mucosal incision on the proximal side using both of dual knife and IT knife nano device. Then we performed a circumferential mucosal incision on the distal side to make an endpoint for submucosal dissection.

Second, a submucosal tunnel was created from proximal side using IT knife nano. The endoscope entered the submucosal layer using the tip of endocap and submucosal tunnel was extended by dissecting submucosa. The loose submucosa of the esophagus allows the insulated tip of knife to be inserted into the submucosa, allowing the small disk shaped electrode of the backside of the insulated tip to safely and efficiently dissect the submucosa. We successfully made a communication between proximal and distal side with good traction against gravity force in order to retract away from the area water pools.
Then we dissected both lateral sides expanding the tunnel. The insulated tip was inserted and hooked to the exposed submucosal layer and moved the knife from inside to outside to get the blade away from esophageal wall to avoid muscle injury and perforation.

We then used a traction method.We attached a line to the endoclip outside the endoscopeand applied the endoclip with line to the back side of the specimen. When the line was pulled through the mouth to give retraction, submucosal layer of the distal side was well visualized and lifted up with good traction.We hooked the backside blade of IT knife to the edge of exposed submucosa and performed submucosal dissection along the muscle direction.
Although the lesion shifted toward the distal side at the end of submucosal dissection, we could keep good traction. Finally, complete circumferential submucosal dissection was done. There was no muscle injury.

A syringe shaped specimen was removed. Here you see the opened specimen.

The resected specimen histologically showed squamous cell carcinoma, with deepest invasion to the lamina propria, margin negative and measuring 66mm by 55mm in size.

Apost-ESD stricture occurred although prophylactic local triamcinolone injection and oral prednisolone. However, it was successfully treated withrepeated endoscopic balloon dilatations.

Here you see technical highlight.

Submucosal tunneling of left side allows the lesion get away from water pooling against gravity. Submucosal tunneling on the left side allowed the lesion to retract away from the area water pools enhancing visualization for the rest of the dissection.

Tunnel expansion with the electrosurgical disc on the backside of the insulated tip allowed us to perform safe submucosal dissection. It also keeps the orientation of the distal side.

Clip line traction allows for improved exposure of submucosa allowing easier identification of the edges of exposed submucosa to direct dissection in narrow esophageal lumen

In conclusion, insulated tip tunneling dissection technique allows safe resection of even large circumferential esophageal cancers. The technique can be assisted with clip line traction.