Post written by Seiichiro Abe, MD, from the Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan.

A 80-year-old male underwent endoscopic submucosal dissection (ESD) for a circumferential esophageal squamous cell carcinoma, 70 mm in size, involving the middle and lower esophagus. Using a dual knife and IT knife nano, a semi-circumferential mucosal incision was made on the proximal side and a circumferential mucosal incision was made at the distal side of the lesion. Next, a submucosal tunnel was created from the proximal side by dissecting the submucosa using an IT knife nano. The loose submucosa of the esophagus allows the insulated tip of  a 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 made a communication between the proximal and distal side against the gravity force in order to get the lesion away from area water pool. An endoclip with attached dental floss was attached to the back side of the specimen. The line was pulled through the mouth to give traction. Dissection of the submucosa lateral to the submucosal tunnel was completed using the IT knife nano. En-bloc resection was achieved, and the syringe-shaped specimen was removed. The resected specimen histologically showed squamous cell carcinoma, with the deepest invasion to the lamina propria, margin negative, and measuring 66 mm by 55 mm in size. As expected, post-ESD stricture developed 8 weeks after ESD despite prophylactic injection of triamcinolone in ESD resection base and oral prednisolone. However, the stricture was successfully treated with endoscopic balloon dilation without hospitalization.

ESD is technically challenging due to the following reasons: 1) The narrow lumen of the esophagus makes gravity counter traction less effective. 2) The resected specimen retracts distally making it difficult to maintain good traction and orientation. 3) The thin wall of the esophagus increases the risk of perforation. However, IT knife tunneling dissection and clip line traction resolve these technical issues and allow us to safely and efficiently perform submucosal dissection while avoiding perforation.

The IT knife tunneling dissection technique allows for safe resection of even large circumferential esophageal cancers. The technique can be assisted with clip line traction.

Note: This video case was awarded the championship of the World Cup of Endoscopy during DDW 2017.

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