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

A 62-year-old woman underwent screening esophagogastroduodenoscopy, and a suspicious 80-mm elevated, laterally spreading lesion was found involving the greater curvature of the upper gastric body. Biopsy showed well-differentiated tubular adenocarcinoma. The patient opted for endoscopic submucosal dissection (ESD).
It was difficult to appreciate the entire lesion due to puddle formation when the patient was in the left lateral position. Changing her position from left to right lateral allowed much better visualization of the lesion by shifting the puddle to the cardia using gravity. After completing circumferential mucosal incision, we added 3 clip-line tractions to the distal side of the lesion to expose the submucosa making dissecting much more efficient in retroflexion. Both the patient position and multiple clip-line traction allowed satisfactory tissue traction to be maintained until the end of the procedure. En-bloc resection was achieved, and following complete defect closure, was accomplished with 3 endoloops and multiple endoclips. The resected specimen was 118 mm by 99 mm in size and revealed well-differentiated tubular adenocarcinoma, with deepest invasion confined to the mucosa measuring up to 86 mm by 70 mm in size. Second-look endoscopy confirmed sustained complete closure.

ESD of sizable early gastric cancers located in the greater curvature of the upper stomach are exceedingly demanding technically because of poor visualization of the entire lesion and gravity-assisted traction. However, altering patient position allowed better visualization of the submucosal plane of the lesion, located in a tremendously challenging location. Moreover, multiple clip-line traction maintained sufficient traction even for the sizable lesion in the greater curvature of the upper stomach. This patient was able to avoid invasive gastrectomy owing to this technique.

It is essential to keep yourself motivated to overcome technical issues in advanced endoscopy. Even with challenging ESD, several tips and tricks can facilitate the procedure, allowing you to provide minimally invasive treatment to your patients.

This case was presented in the ASGE video plenary session during DDW 2019.

Read the full article online.

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