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Traction method for endoscopic subserosal dissection

Open AccessPublished:February 07, 2020DOI:https://doi.org/10.1016/j.vgie.2020.01.003

      Abbreviations:

      ESSD (endoscopic subserosal dissection), EUS-FNA (EUS-guided fine-needle aspiration), SET (subepithelial tumor)
      GI subepithelial tumors (SETs) are frequently found during screening EGD. The vast majority of SETs are generally asymptomatic and clinically insignificant. However, certain types may be malignant or have the potential to progress to malignancy, such as carcinoids, lymphomas, glomus tumors, and GI stromal tumors. Noninvasive diagnostic methods, such as EUS, still provide challenges in making an accurate diagnosis and definition of lesion characteristics. Histopathologic examination of the tumor still remains the criterion standard in achieving a correct assessment and diagnosis of the lesion.
      • Cho J.W.
      Current guidelines in the management of upper gastrointestinal subepithelial tumors.
      To obtain a sample of the lesion, bite-on-bite biopsy
      • Ji J.S.
      • Lee B.I.
      • Choi K.Y.
      • et al.
      Diagnostic yield of tissue sampling using a bite-on-bite technique for incidental subepithelial lesions.
      or EUS-guided fine-needle aspiration (EUS-FNA) may be effective but is not always feasible.
      • Moon J.S.
      Endoscopic ultrasound-guided fine needle aspiration in submucosal lesion.
      Otherwise, a complete resection can be achieved with peroral endoscopic tumor excision,

      Onimaru M, Inoue M, Bechara R, et al. Clinical outcomes of per-oral endoscopic tumor resection for submucosal tumors in the esophagus and gastric cardia. Dig Endosc. Epub 2019 Jun 24.

      full-thickness dissection,
      • Cai M.
      • Zhou P.
      • Lourenço L.C.
      • et al.
      Endoscopic full-thickness resection (EFTR) for gastrointestinal subepithelial tumors.
      or endoscopic subserosal dissection (ESSD).
      • Liu F.
      • Zhang S.
      • Ren W.
      • et al.
      The fourth space surgery: endoscopic subserosal dissection for upper gastrointestinal subepithelial tumors originating from the muscularis propria layer.
      The first ESSD series performed for the removal of SETs originating from the muscularis propria was successfully reported by Liu et al.
      • Liu F.
      • Zhang S.
      • Ren W.
      • et al.
      The fourth space surgery: endoscopic subserosal dissection for upper gastrointestinal subepithelial tumors originating from the muscularis propria layer.
      Here, we present a case demonstrating ESSD of a gastric SET on the posterior wall of the gastric fundus (Video 1, available online at www.VideoGIE.org).
      A 56-year-old woman with no significant medical history underwent screening EGD, during which a 2-mm SET was observed in the gastric fundus (Fig. 1). The overlying mucosa appeared normal. EUS assessment showed a probable muscular layer origin of the lesion. However, the lesion was thought to be too small for FNA; hence, FNA was not carried out. The case was discussed with the patient, and we then decided to perform ESSD.
      Figure thumbnail gr1
      Figure 1Endoscopic view showing submucosal lesion of gastric fundus.
      ESSD was carried out with the patient under general anesthesia, with endoscopic insufflation of carbon dioxide. The procedure was performed with a single-channel gastroscope (GIF-Q260J; Olympus Medical System Co, Tokyo, Japan), and a super-soft transparent hood was attached on the tip of the scope (Space Adjuster; TOP, Tokyo, Japan). A triangle-tip knife with jet function (TTJ KD-645L; Olympus) was used for incision and dissection. The Erbe VIO300D System (Erbe Elektromedizin Gmbh, Tubingen, Germany) was set on program Endo cut Q effect 2 and Spray coag effect 2, with maximum power 50 W.
      After creating a circumferential marking around the lesion, a solution containing saline and indigo carmine was injected into the submucosal layer. A C-shaped mucosal incision was made on the anal side of the lesion with the triangle-tip knife with jet function. Stepwise submucosal dissection was performed to create a small flap. After this, the endoscope was withdrawn. One open-close clip was placed into the working channel and grasped a snare. Then, it was reinserted into the stomach. In this way, the clip could grasp both lesion and snare together. Two additional clips were placed to secure the snare and to achieve an appropriate multipoint countertraction on the lesion (Figs. 2 and 3). At this point, dissection could be performed easily, with good visualization and without the need for subserosal injections (Figs. 4 and 5).
      • Liu F.
      • Zhang S.
      • Ren W.
      • et al.
      The fourth space surgery: endoscopic subserosal dissection for upper gastrointestinal subepithelial tumors originating from the muscularis propria layer.
      After completion of the dissection, it was possible to appreciate the remaining serosal tissue and pancreas surface beyond it (Fig. 6). En bloc resection was completed without any adverse events, and the incision site was completely closed with clips. Histopathologic assessment confirmed a leiomyoma. The patient started eating 3 days after the ESSD. Postprocedural medications included hydration and intravenous proton pump inhibitors for 3 days, followed by proton pump inhibitors by mouth for 4 weeks.
      Figure thumbnail gr2
      Figure 2Endoscopic view showing snare-and-clips multipoint traction method.
      Figure thumbnail gr3
      Figure 3Submucosal lesion grasped with clips and snare.
      Figure thumbnail gr4
      Figure 4Endoscopic view showing dissection plane between muscular and serosal layers.
      Figure thumbnail gr5
      Figure 5Endoscopic view showing dissected gastric subepithelial tumor.
      Figure thumbnail gr6
      Figure 6Endoscopic view showing exposure of the serosal layer.
      In summary, the ESSD with traction method is a feasible and safe procedure for patients with GI subepithelial tumors.

      Disclosure

      Dr Inoue is an advisor for Olympus and TOP Corporation and the recipient of educational grants from Olympus and Takeda Pharmaceutical. All other authors disclosed no financial relationships relevant to this publication.

      Supplementary data

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