Post written by Giuliano Francesco Bonura, MD, from the Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Carpi, Italy.

A 65-year-old man was referred to our unit with long-segment Barrett’s esophagus (Prague C6, M10) with 2 bulky adjacent sessile lesions (30 mm and 15 mm) positive for adenocarcinoma at biopsies. Magnification endoscopy with narrow-band imaging also revealed suspicious mucosal and microvessel pattern in the adjacent flat Barrett’s esophagus.

EUS found a suspicious submucosal invasion with intact proper muscle layer. CT scan showed a moderate esophageal variceal ectasia not visible at endoscopic evaluation. No sign of liver cirrhosis was identified with abdominal US, elastography, and laboratory examinations.

We performed endoscopic submucosal dissection (ESD) using a next-generation ultraslim therapeutic endoscope (EG-840 TP Slim Treatment Gastroscope; Fujifilm, Tokyo, Japan), which has a 7.9-mm insertion tube with a large 3.2-mm working channel, allowing one to use current dedicated ESD devices. Also, it is powered by an expanded angulation (210 up/160 down) that improves maneuverability significantly.

Moreover, the latest-generation hybrid-knife (HYBRIDknife flex I-Type; Erbe, Tübingen, Germany) was used, further improving the cut and coagulate precision together with tissue elevation by high-pressure injection. The procedure was performed using amber-red-color imaging (Fujifilm) mode specifically designed to enhance the visibility of deep vessels and submucosal space/muscle layer to facilitate third-space endoscopic procedures.

After significant bleeding after first mucosal incision at the distal margin, the initial plan of tunnel creation method was changed, and a complete circumferential incision was performed followed by ESD assisted by saline-immersion technique and double clip-line traction method. Of note, during ESD a dense network of marked dilated esophageal varices (up to 7 mm) was encountered in the third space, identified, and treated with hemostatic forceps (soft coag6.5) or knife (forced coag0.3 or spray coag2.6).

Finally, the lesion was resected en bloc, and no adverse events occurred. The patient was discharged home 3 days later asymptomatic, and histopathologic evaluation discovered an intramucosal adenocarcinoma (pT1a, m2, L0, V0, Bd1, R0, G1). At 3-month follow-up, no significant stricture or residual/recurrence neoplastic lesion were observed.

This video demonstrates how challenging endoscopic resections can be successfully and safely managed. Importantly, the latest innovations in endoscopic technology and advanced imaging techniques—combined with the relatively new saline-immersion method and high operator expertise—enabled the complete procedure to be performed without adverse events, resulting in curative resection.

Such a challenging resection required a comprehensive approach. This includes careful inspection of the lesion, a high level of expertise in advanced endoscopic resection techniques and management of potential adverse events, as well as staying continuously updated on the latest advancements in endoscopic technology.

Endoscopic image of the dense network of marked dilated esophageal varices in the third space below the lesion under amber-red-color imaging mode.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.