Post written by Shunya Takayanagi, MD, from the Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan, and Department of Medicine and Bergen Research Group for Advanced Gastrointestinal Endoscopy (BRAGE), Haukeland University Hospital, Bergen, Norway.

In this case, we attempted endoscopic submucosal dissection (ESD) for an intramucosal carcinoma on the lesser curvature of the gastric angle accompanied by an ulcer scar. During the procedure, we encountered severe submucosal fibrosis, which led us to convert the procedure to endoscopic subserosal dissection. Ultimately, we successfully achieved R0 resection.

A gastric ulcer scar may be known preoperatively in some patients, but it is not uncommon to unexpectedly encounter severe fibrosis—likely resulting from prior ulceration—during ESD. Demonstrating management of this challenging fibrosis in real time can provide crucial guidance to other endoscopists.

The key lesson is to avoid dissecting the fibrotic tissue directly. Although it would be ideal to dissect through the fibrosis, it is often infeasible; severe fibrosis can obscure the appropriate dissection plane, and fear of perforation may lead to a superficial approach that inadvertently breaches the lesion.

When traction is applied in these circumstances, even a small defect can quickly enlarge. Once the lesion is injured, it becomes difficult to re-establish the proper plane, threatening completion of ESD. By intentionally dissecting the muscularis propria beneath the fibrotic segment, one can maintain orientation and traverse the scar as a cohesive unit.

This strategy carries an increased risk of perforation and requires meticulous muscularis dissection, but it can facilitate safe completion of resection. In our case, we extended dissection into the subserosal layer. However, limiting dissection to the muscularis propria may be sufficient once the fibrotic segment has been traversed.

Depth of dissection for severe fibrosis in the submucosa. The fibrotic tissue should be carefully dissected (blue arrow), but determining the dissection plane is challenging because of the inability to create a blue submucosal cushion. Concerns about muscle injury may result in a shallow dissection plane, damaging the lesion (red arrow). Dissection beneath the fibrosis facilitates achieving R0 resection (green arrow).

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