Post written by Lovekirat Dhaliwal, MBBS, and Prasad G. Iyer, MD MSc, from the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.

A 65-year-old man with alcohol-related liver disease and COPD was recently diagnosed with esophageal adenocarcinoma on a background of varices. EUS demonstrated a 2-cm hypoechoic mass invading into deep mucosa. PET-CT scan showed localized disease with no distant metastasis. Considering the patient’s age and comorbidities, a decision was made to proceed with water-pocket endoscopic submucosal dissection (WP-ESD). The procedure was done under general anesthesia with endotracheal intubation. After marking the boundaries of the lesion, we created an underwater submucosal tunnel 1 cm proximal to the oral side of the lesion. Underwater dissection of the submucosa allowed better identification of submucosal vessels for preemptive coagulation. Once the submucosal tunneling was completed boundaries of the lesion were incised using the Clutch-Cutter knife. After careful dissection of the lesion, the resected specimen was removed and sent for histopathology. The resection bed was clean and dry. The patient was discharged after an uneventful stay and no delayed bleeding was reported. Pathology revealed intramucosal adenocarcinoma with negative deep and lateral margins.

Endoscopic resection of an esophageal lesion in the presence of varices is associated with increased risk of bleeding. This video shows the safety and efficacy of WP-ESD in patients with varices. WP-ESD provides better visualization than the conventional air insufflation method and allows hemostasis to be secured before the tumor is resected endoscopically.

In this video, we emphasized the safety of WP-ESD in patients with varices. We believe after seeing this video, other endoscopists will be more comfortable in adopting this technique.

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