Post written by Kurato Miyazaki, MD, from the Division of Gastroenterology and Hepatology, Department of Internal Medicine, and the Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.

Red dichromatic imaging (RDI) is a recently developed novel image-enhanced endoscopy that enables one to visualize blood vessels in the deep submucosa by utilizing 3 different relatively long wavelength lights (green, amber, red). Especially, RDI mode 2 enhances the red tone of deep blood vessels and significantly improves the visibility of blood vessels. Here, we present a case showing RDI is effective for a safe ESD in cases of high risk of bleeding.

The patient had a past history of liver cirrhosis and previous endoscopic variceal ligation (EVL) for esophageal varices. A superficial esophageal squamous cell carcinoma was found on the scar of the EVL, and untreated esophageal varices were adjacent to the lesion. The patient was also taking warfarin for portal vein thrombosis.

In this case, we were confidently able to identify the deep vessels and perform safe injection under RDI mode 2 to avoid injuring blood vessels. As a result, we were able to complete endoscopic submucosal dissection (ESD) quickly without encountering massive bleeding.

The lumen of esophagus is narrow, so even a small amount of bleeding can significantly prevent visibility. In addition, the esophageal wall is thin, and impaired visibility due to submucosal hematoma would be a cause of perforation. Therefore, prevention of vessel injury during initial submucosal injection is key for successful ESD. This case is valuable to address the usefulness of RDI, developed as a novel kind of image-enhanced endoscopy.

For high-risk bleeding cases and difficult-to-treat cases, ESD can be performed more safely by using RDI mode 2 to confidently identify the blood vessels. It is warranted to confirm clinical usefulness of RDI in future clinical trials.

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