ESD OF CIRCUMFERENTIAL ESOPHAGEAL SQUAMOUS CELL CARCINOMA, “MUCOSAL BRIDGE TRACTION TECHNIQUE”

Introduction:

We present the case of a circumferential oesophageal submucosal endoscopic dissection in a 56-year-old patient who presented a squamous esophageal squamous carcinoma of 10 cm in superficial length, without evidence of lymph node involvement by EUS, CT and PET-Scan. ESD was decided as the preferred first-line treatment according to the patient decision.

Brief description of the technique:

The procedure was performed in the operating room, with the patient in supine position, intubated under mechanical ventilation, PEEP +5.

After marking the limits of the lesion, a circumferential mucosal incision was made with flush knife 1.5 mm at the anal side of the lesion. Then a semi circumferential proximal mucosal incision was made. Tunneling with flush knife and IT nano was done.

"Mucosal bridge traction technique": Before completing submucosal dissection, 2 mucosal "bridges" were left on the oral side, to help traction of the lesion, when doing submucosal tunneling dissection. At the end of the procedure the mucosal bridges were cut. The procedure was completed in 2 hours and 45 minutes.

The final histology showed an intramucosal squamous cell carcinoma that contact the muscularis mucosa (M3) at two points, without evidence of lymphovascular or submucosal involvement.

The patient presented a stenosis after 3 weeks of the procedure, despite corticosteroid treatment, requiring endoscopics treatments.

9 months after the intervention there is no evidence of local or distant recurrence, and the patient has a normal diet, having required 17 endoscopic balloon dilation sessions to date.

Conclusions:

The tunneling technique is useful in the submucosal dissection of extensive esophageal lesions. This novel technique, "mucosal bridge traction technique" might be helpful in some cases of ESD, as an alternative traction technique.