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

A 96-year-old man underwent definitive radiotherapy for extensive early esophageal squamous cell carcinoma (SCC) involving the middle esophagus. Three months after radiotherapy, a residual tumor was detected during esophagogastroduodenoscopy. A 50-mm circumferential flat lesion was evaluated. Endoscopic submucosal dissection (ESD) was performed under general anesthesia. Using a dual knife, we first made a semi-circumferential mucosal incision around the proximal tumor margin. A circumferential mucosal incision was then completed at the distal end of the lesion. Changing to an IT knife nano, submucosal tunnel was created starting from the left lateral edge of the lesion. The small disk-shaped electrode on the backside of the insulated tip of the IT knife nano could be used to dissect the submucosa safely and efficiently. With continual dissection starting proximally, the dissected proximal edge came through to the distal margin completing the tunnel. The submucosal tunnel was extended with the use of IT knife nano dissecting from the left lateral aspect. To improve visibility of the dissection plane, clip-traction method with dental floss on the end of an endoscopic clip was used. Submucosal fibrosis was dissected with a dual knife. En bloc resection was achieved in 85 minutes, and injection of 100-mg triamcinolone acetonide was performed into the ulcer base to prevent post-ESD stricture. Histopathology was consistent with SCC, 80 ×37 mm in size, with the invasion depth to the lamina propria without lymphovascular invasion. Follow-up endoscopy revealed no esophageal stricture. There was no local or distant metastasis during the 21 months of follow-up. This elderly patient could avoid invasive esophagectomy.

Salvage ESDs are demanding technically because of submucosal fibrosis after radiation therapy. In addition, ESDs for circumferential esophageal cancer are technically challenging. However, endoscopic submucosal tunneling dissection using IT knife nano and dual knife allowed us to perform ESD safely and efficiently. Salvage ESD for circumferential esophageal cancer was effective for local treatment after radiation.

ESD is established as a minimally invasive treatment option. However, we sometimes encounter technical difficulty. In any ESD case, it is important to learn basic incision and dissection techniques and thoughtful strategy for this challenging situation.

This video case was selected in JGES (Japan Gastroenterological Endoscopy Society) video award session during the 97^th congress of JGES.

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