Subscribe to RSS
Endoscopic submucosal dissection of Barrettʼs neoplasia into a stenosis: circumferential tunneling strategy with clip-and-line traction
Endoscopic submucosal dissection (ESD) is now validated for Barrett’s neoplasia in case of visible lesions > 15 mm  , and tunneling dissection   is particularly effective when associated with clip-and-line traction . Here we report the case of a 57-year-old man referred for a short circumferential stenosis with high grade dysplasia at 28 cm from the dental arch. The stricture was not passable with a standard gastroscope, and we used a transnasal scope to avoid deep invasion and to confirm the distal margin of the neoplastic lesion under the stricture.
After submucosal injection, we created a circumferential incision and trimmed the superior edge 2 cm above the stricture ([Fig. 1], [Video 1]). Circumferential dissection allowed us to create a circumferential flap where we fixed clip-and-line traction.
Video 1 Endoscopic submucosal dissection of Barrett’s neoplasia into a stenosis: circumferential tunneling strategy with clip-and-line traction.
We then created several submucosal tunnels, expanding them on both sides and progressively extending the circumferential flap. Thanks to the tunnel and traction, we were able to find a thin submucosal layer under the fibrotic area, which allowed us to perform submucosal dissection through the stricture circumferentially. At 32 cm from the dental arch, we created an inferior incision from the tunnel. We finished the inferior circumferential incision and the submucosal dissection. Stenosis was visible on the extracted specimen ([Fig. 2]) but disappeared in the esophageal lumen. Pathology on the specimen showed adenocarcinoma in situ and significant thickening of the muscularis mucosae.
This suggests that the circumferential stenosis was superficial and that resection is safe and feasible using clip-and-line traction and the circumferential tunneling dissection technique with a progressive strategy from the upper to the lower edge of the stricture. Stricture did not recur at 3 months’ follow up.
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
17 December 2020 (online)
© 2020. Thieme. All rights reserved.
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
- 1 Weusten B, Bisschops R, Coron E. et al. Endoscopic management of Barrett’s esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2017; 49: 191-198
- 2 Yang D, Zou F, Xiong S. et al. Endoscopic submucosal dissection for early Barrett’s neoplasia: a meta-analysis. Gastrointest Endosc 2018; 87: 1383-1393
- 3 Linghu E, Feng X, Wang X. et al. Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions. Endoscopy 2012; 45: 60-62
- 4 Pioche M, Mais L, Guillaud O. et al. Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions. Endoscopy 2013; 45: 1032-1034
- 5 Jacques J, Legros R, Rivory J. et al. The “tunnel + clip” strategy standardised and facilitates oesophageal ESD procedures: a prospective, consecutive bi-centric study. Surg Endosc 2017; 31: 4838-4847