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Wide-field ESD for Barrett's adenocarcinoma at the gastroesophageal junction: technical approaches to facilitate en bloc R0 resection
Endoscopic submucosal dissection (ESD) for Barrett's esophagus (BE) neoplasia is associated with high en bloc resection and an acceptable safety profile but with suboptimal curability rates (range, 56%-59%).1 Two large Western studies showed that low R0 resection rates resulted from the high rate of positive lateral margins in ESD specimens (range, 82%-86%), which prompted either salvage ESD or additional surgical treatment.2,3 A U.S. multicenter ESD study found positive lateral margins in up to 70% of Barrett's adenocarcinoma (BA) at the gastroesophageal junction (GEJ) because of the increased technical complexity, poor maneuverability, and difficulty in evaluating the lesion’s margin.Gauze extension method for specimens resected by endoscopic submucosal dissection
Endoscopic submucosal dissection (ESD) is a standard and reliable procedure for resection of GI neoplasms. Although ESD allows en bloc resection of large GI neoplasms,1 ESD specimens tend to contract because of burning and scarring of the margins during ESD (Fig. 1). When preparing ESD specimens for pathologic examination, including evaluation of the margins, specimens should be extended and pinned on a fixing board as quickly as possible.2,3 However, in most cases, the normal marginal mucosa from ESD specimens is thin and fragile, especially from the colon.Endoscopic submucosal dissection and tunneling procedures using novel image-enhanced technique
Recent innovations in image-enhanced endoscopy allow early detection and management of GI lesions. In this study, we aim to analyze the utility of texture and color enhancement imaging (TXI) and red dichromatic imaging (RDI) during endoscopic submucosal dissection (ESD) and submucosal tunneling procedures.The utility of image-enhanced endoscopy and Lugol’s for the assessment of esophageal squamous carcinoma
Esophageal squamous cell carcinoma (ESCC) is the most commonly diagnosed esophageal cancer.1 Previously, diagnoses in the late stages of disease led to a poor prognosis and limited treatment. However, advancements in optical diagnosis and resection techniques have allowed for improved detection, characterization, and therapy. We present a case that highlights the utility of image-enhanced endoscopy and Lugol’s in the assessment of ESCC (Video 1, available online at www.giejournal.org ).Endoscopic through-the-scope suturing
There is growing interest in closure of larger mucosal defects, given the increasing use of endoscopic resection for early GI neoplasia and the advent of submucosal endoscopy, including peroral endoscopic myotomy. Existing closure methods include through-the-scope clips, over-the-scope clips, and over-the-scope suturing. Although over-the-scope clips and over-the-scope suturing allow closure of large defects, both require endoscope removal for device application and may have difficulty in treating lesions in the proximal colon or the small intestine.Esophageal endoscopic submucosal dissection on postendoscopic variceal ligation scars with injection under red dichromatic imaging
Red dichromatic imaging (RDI) has recently been developed, and there have been several reports evaluating the usefulness of RDI for endoscopic diagnosis or treatment.1-11 RDI enables visualization of blood vessels in deep submucosa using 3 different relatively long wavelength lights (green, amber, and red) (Fig. 1).12 Similar to narrow-band imaging, we can easily switch to RDI by pressing the button on the endoscope. RDI has 3 modes that can be switched in sequence by pressing the button on the image processor (EVIS X1; Olympus Medical Systems, Tokyo, Japan).Endoscopic submucosal dissection of cervical esophageal cancer with hypopharyngeal invasion using a curved laryngoscope
A 71-year-old woman presented with dysphagia in May 2020. Laryngoscopy did not show abnormal findings. However, upper GI endoscopy revealed a tumor in the cervical esophagus that was subsequently histopathologically diagnosed as squamous cell carcinoma. CT showed no evidence of metastases. Because she refused to undergo surgery or chemoradiation, which was invasive treatment, we planned to perform endoscopic resection and explained to the patient that she would develop esophageal stenosis after the procedure.Successful removal of a giant esophageal lipoma with hybrid endoscopic submucosal dissection
We report a case of a 47-year-old man who presented with dysphagia with an Eckardt score of 6 and weight loss. CT imaging of the chest visualized a 7-cm hypodense lesion occupying both the middle and lower sections of the esophagus (Fig. 1). This presentation was characteristic of an esophageal lipoma. A multidisciplinary team of thoracic surgeons and endoscopists chose endoscopic submucosal dissection (ESD) of the lesion as the optimal next step (Video 1, available online at www.giejournal.org ).A novel curved wire retraction device for endoscopic submucosal dissection
Endoscopic submucosal dissection (ESD) is a well-established minimally invasive endoscopic technique for the en bloc resection of early GI malignancies.1 Adoption of the technique in the West has been limited by its difficult learning curve, longer procedure times, and risk of adverse events. Device innovation is needed to make the procedure easier and safer to perform. A known limitation of ESD is that the procedure is performed through a single device, and there is no “surgeon’s second hand”2 to provide traction on the lesion.Emerging therapies in translational endoscopy: new frontiers in endoscopic submucosal dissection
The field of therapeutic endoscopy is evolving with a variety of new endoscopic surgical procedures. One such procedure, endoscopic submucosal dissection (ESD), has proven efficacy, yielding high margin-negative (R0) resection rates with low rates of adverse events and recurrence.1 However, the technical complexity, long procedure duration, and steep learning curve associated with ESD have led to relatively slow adoption. Although there has been an increased trend in devices and tools that may assist with ESD, there remains a paucity of advances in endoscopic technology, which are much needed given these known barriers.Evolution of re-epithelialization postcircumferential esophageal endoscopic submucosal dissection
A 62-year-old woman with C1M5 Barrett's with multifocal high-grade dysplasia on biopsy was referred for management. Various treatment options were reviewed, including endoscopic mucosal resection, radiofrequency ablation, staged endoscopic submucosal dissection (ESD), and complete circumferential ESD. The decision was made to proceed with complete circumferential ESD.Red dichromatic imaging in peroral endoscopic myotomy: a novel image-enhancing technique
A 40-year-old man presented with a 1-year history of difficulty in swallowing liquids and solids. His Eckhart’s score was 6 of 12. EGD showed dilated esophagus with liquid stasis and mild resistance noted across the gastroesophageal junction. Esophageal manometry showed elevated integrated relaxation pressure with panesophageal pressurization (achalasia cardia type II). Peroral endoscopic myotomy (POEM) was planned and was performed using the novel Evis X1 endoscopy (Olympus Corporation, Tokyo, Japan) system.Endoscopic submucosal dissection for superficial pharyngeal carcinoma using transnasal endoscope
Detection of superficial pharyngeal carcinoma is becoming more common with advances such as narrow-band imaging and blue-laser imaging.1,2 Endoscopic submucosal dissection (ESD) for superficial pharyngeal carcinoma is useful as a minimally invasive treatment.3,4 However, lesions at the posterior wall of the oropharynx are usually difficult to resect using a conventional transoral endoscope because they are perpendicular to the muscle layer and the subepithelial layer is quite narrow at this site (Fig. 1).Continuous saliva suction tube to prevent aspiration pneumonia during upper GI endoscopy
Endoscopic submucosal dissection (ESD) has been established as a minimally invasive treatment modality and has been adopted worldwide for the treatment of early GI tract cancer. However, aspiration pneumonia, a sedation-related adverse event, is reportedly detected on postoperative CT images in 32.0% of cases after esophageal ESD1 and 6.6% to 14.4% of cases after gastric ESD.2,3 Clinical symptoms in the majority of patients are often mild, but symptoms can become serious in elderly patients. Furthermore, because the number of endoscopic treatments for elderly patients is expected to continue to increase in the future, a new strategy is needed to prevent aspiration pneumonia associated with liquid reflux and saliva retention in the oral cavity.Circumferential endoscopic submucosal dissection for the treatment of ultra-short-segment Barrett’s adenocarcinoma with multifocal dysplasia
Ultra-short-segment Barrett’s esophagus is defined as intestinal metaplasia at the esophagogastric (EG) junction measuring less than 1 cm in length.1 Endoscopic resection of Barrett’s adenocarcinoma (BA) should be generally followed by ablation therapy to achieve complete eradication of all intestinal metaplasia (IM), thereby decreasing the likelihood of recurrent displasia.2 Although circumferential endoscopic submucosal dissection (ESD) for BA can provide both tumor resection and complete removal of IM, avoiding subsequent ablation procedures, the number of cases reported is scarce.Successful resection of a giant pedunculated pharyngeal liposarcoma by endoscopic submucosal dissection with countertraction using grasping forceps
Hypopharyngeal and esophageal liposarcomas are very rare and are mainly diagnosed as pedunculated submucosal tumors.1 Mobile pedunculated tumors of the hypopharynx have the risk of causing airway obstruction and should hence be extracted.2,3 Here, we report a rare case of a patient in whom endoscopic submucosal dissection (ESD) with countertraction using grasping forceps was performed for a giant pedunculated pharyngeal liposarcoma.Salvage circumferential endoscopic submucosal dissection for refractory dysplastic Barrett’s esophagus
A 64-year-old woman initially underwent endoscopy for reflux symptoms and was found to have C7M8 Barrett’s esophagus with biopsies demonstrating high-grade dysplasia. She was referred to a tertiary esophageal center, which performed endoscopic mucosa resection.Retrograde percutaneous transgastric esophageal endoscopic submucosal dissection: a peculiar endoscopic submucosal dissection technique for therapy of esophageal cancer with esophageal stenosis after chemoradiation therapy
The patient was a 69-year-old man who had received chemoradiotherapy for T3N2M0, stage III cervical esophageal cancer 10 years earlier and exhibited complete response. He developed cervical esophageal stenosis caused by fibrosis as a result of treatment and experienced dysphagia within 1 year after treatment.Microperforation due to segmental absence of intestinal musculature during endoscopic submucosal dissection for early esophageal cancer: a case study
Endoscopic submucosal dissection (ESD) has been widely applied for early esophageal cancer in recent years, but perforation is sometimes an adverse event.1 Here, we report a case of a patient found, during ESD, to have a segmental absence of intestinal musculature (SAIM) that caused a microperforation.Dynamic and multifocal clip and band countertraction for endoscopic submucosal dissection
Endoscopic submucosal dissection (ESD) is a challenging technique that bears a significant risk of perforation. Given that standard endoscopy, unlike laparoscopy, does not permit traction, the difficulty of ESD is augmented. Countertraction techniques have been shown to improve the speed of dissection, the rate of R0 resection, and the safety of the procedure.1-3Endoscopic submucosal dissection using a new super-soft hood and the multipoint traction technique
Endoscopic submucosal dissection (ESD) is considered the standard of care for resection of early gastric cancers.1 To perform this technique in a safe and effective manner, visualization of the submucosal layer and appropriate tissue tension are required. To achieve this, a hood and a countertraction method may be used.2-6 Here, we introduce ESD using a new super-soft hood7 and the advanced multipoint traction technique.8Endoscopic submucosal dissection for Barrett’s-associated adenocarcinoma in a patient with decompensated cirrhosis and esophageal varices
Presently, endoscopic resection is the preferred treatment of choice for patients with Barrett’s dysplasia, especially high-grade dysplasia and even early esophageal adenocarcinoma.1 However, among the various endoscopic resection techniques, endoscopic submucosal dissection (ESD) may carry a higher risk of adverse events in patients with cirrhosis because of the low platelet count, coagulopathy, and presence of esophageal varices.2,3 To date, only small case series of esophageal ESDs, especially for squamous cell carcinoma, have been reported from Asia in patients with cirrhosis, but the included patients were well compensated, with platelet counts >50 k/μL.Autologous esophageal mucosa with polyglycolic acid transplantation and temporary stent implantation for the prevention of esophageal stenosis after circumferential endoscopic submucosal dissection
A 53-year-old man underwent circumferential endoscopic submucosal dissection (ESD) in our hospital for a superficial esophageal neoplasm 10 cm in circumference and approximately 29 to 39 cm from the incisors. To prevent postoperative esophageal stenosis, we performed implantation of autologous esophageal mucosa with polyglycolic acid (PGA) and placed a temporary stent to fill the artificial ulcer in the esophagus.Endoscopic submucosal dissection of esophageal metastatic melanoma
A 65-year-old man underwent surgical excision with lymph node dissection for a scalp melanoma in 2011. In 2018, he presented to his melanoma oncologist for routine follow-up and subsequently underwent an upper endoscopy for reflux symptoms. His upper endoscopy revealed a pigmented lesion in the esophagus, biopsy specimens that showed malignant melanoma. Positron emission tomography/CT and magnetic resonance imaging of the brain revealed no evidence of distant metastases. He was referred for further endoscopic evaluation and treatment.Robotic-assisted surgical endoscopy: a new era for endoluminal therapies
Minimally invasive endoscopic procedures are associated with lower adverse events and shorter hospital stays compared with conventional open surgery.1,2 However, some advanced endoscopic procedures, including endoscopic submucosal dissection (ESD), natural orifice transluminal endoscopic surgery (NOTES), and suturing, have typically required specialized training and a certain amount of experience to achieve competency. Therefore, these procedures are not widely performed in nonspecialized centers.
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