Post written by Shaimaa Elkholy, MD, Karim Essam, MD, and Mohamed El Sherbiny, MD, from the Gastroenterology Division, Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt.

Our article highlights the role of submucosal tunneling endoscopic resection (STER) in managing 2 highly challenging esophageal subepithelial lesions. Although STER has become an established minimally invasive technique for selected lesions, its application in anatomically complex situations remains technically demanding. We present 2 real-world cases in which STER was successfully performed despite significant procedural challenges, demonstrating its feasibility when meticulous planning and advanced endoscopic expertise are available.

Both patients presented with characteristics that traditionally increase procedural complexity. In the first case, the lesion was located only 1 mm from the aortic arch in a patient with severe systemic comorbidities, including systemic lupus erythematosus, complicated Crohn’s disease, previous abdominal surgeries, and dependence on partial parenteral nutrition.

In the second case, the lesion measured 8 × 5 cm, extended across multiple esophageal walls, restricted endoscope maneuverability, and required full-thickness myotomy with controlled mediastinal exposure. These cases illustrate that challenging anatomy alone should not necessarily preclude an endoscopic approach when careful multidisciplinary evaluation and experienced operators are involved.

Both lesions were successfully removed en bloc without major adverse events, and both patients experienced favorable clinical outcomes. Our article showcases that STER can be successfully applied even with highly challenging esophageal subepithelial lesions, including those adjacent to critical mediastinal structures or of unusually large size.

These cases note the importance of individualized procedural planning, tailored tunneling and dissection strategies, and multidisciplinary decision-making. We hope our experience encourages further multicenter studies evaluating STER with high-risk and anatomically complex esophageal lesions to better define patient selection, technical modifications, long-term outcomes, and the broader role of STER as an alternative to surgery.

Endoscopic steps of submucosal tunneling endoscopic resection in case 2. A, Endoscopic view showing a large subepithelial lesion (white arrow). B, Submucosal injection with diluted methylene blue. C, Mucosal incision to create the tunnel opening. D, Submucosal dissection of the lesion from surrounding tissues (red arrow pointing to the lesion). E, Tumor inside the tunnel. F, Snare holding the lesion inside the tunnel prior to extraction (black arrow). G, Empty tunnel following lesion extraction. H, Closure of the tunnel entry using endoscopic clips. I, Gross specimen showing a well-encapsulated lesion with a smooth outer surface.

Read the full article online.

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