Andres Sanchez-Yague, MD, from Hospital Costa del Sol in Marbella, Spain shares this video case “‘Unchaining’ a stuck early gastric cancer by endoscopic submucosal dissection.”
A 67-year-old male with a past medical history of distal gastrectomy was diagnosed with a metachronous early gastric cancer at the cardia. The patient refused total gastrectomy and was referred to our center for ESD. The procedure was performed using a standard technique with the Dual Knife. We began marking around the lesion using the knife, then a circumferential incision was performed and we continued with dissection under the lesion. There was a central area that couldn’t be removed with the knife even exerting mechanic pressure. We even tried electrocoagulation with argon plasma to no effect. At this area we found several metallic structures consistent with a staple line. We managed to dislodge some of the staples creating a thinner area that could be resected using a snare.
Pathology examination revealed a well-differentiated adenocarcinoma with focal infiltration of the lamina propria, free vertical and lateral margins and no lymphovascular invasion. The fibrous pedicle was free of disease.
Follow up endoscopy showed no residual lesion.
This video shows an uncommon case where a gastric cancer recurrence in a patient with partial gastrectomy grows on top of the staple line. The underlying staple line prevented complete resection using ESD, making it necessary to partially remove the staples prior to snare resection of the fibrotic area.
In patients with gastric lesions and prior partial gastrectomy is important to determine the course of the staple line. Lesions arising on top of the staple line are challenging due to the presence of fibrosis and the staples. Though technically difficult, it’s possible to remove the staples using a knife.
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