Three-arm endoscopic mucosal resection for gastric adenocarcinoma of fundic gland type

A 65-year-old man was diagnosed with intramucosal carcinoma by endoscopy and pathological biopsy; the tumor was 10 mm in size and located in the greater curvature of the gastric body ([Fig. 1 a]). It was difficult to perform endoscopic submucosal dissection (ESD) on the greater curvature of the gastric body. We therefore proposed a three-arm endoscopic mucosal resection (TA-EMR) technique in which two nasal oxygen tubes, about 80 cm in length, were taped to the outside of the endoscope to become a double additional working channel (AWC) ([Video 1]).

Fig. 1 The three-arm endoscopic mucosal resection technique to remove gastric adenocarcinoma of fundic gland type. a A 10-mm gastric adenocarcinoma of fundic gland type was located in the greater curvature of the gastric body. b The snare was tightened after lifting the anal and oral sides of the lesion. c The front end of the endoscope looked like “three arms.” d The wound was clean. e The vertical and horizontal margins were negative.

Video 1 The process of endoscopic mucosal resection assisted by two self-made additional working channels, named the three-arm endoscopic mucosal resection technique.

After a 30-mm snare was placed around the lesion through the first AWC, the lesion was grasped from the anal and oral sides by a foreign body forceps through the second AWC and a reopenable clip through the endoscope channel, respectively, to ensure negative margins ([Fig. 1 b]). The assistant grasped the mucosal layer to avoid perforation during resection caused by excessive lifting. Narrow-band imaging confirmed that the lateral margin of the lesion was fully contained after tightening the snare ([Fig. 1 c]). Although there was active bleeding after resection of the lesion, electrocoagulation could be performed easily, with a good visual field of the wound; no perforation was observed ([Fig. 1 d]). The whole procedure took about 15 minutes.

Histological and immunohistochemical examination showed gastric adenocarcinoma of fundic gland type, with submucosal invasion depth of 800 μm, and negative vertical and horizontal margins ([Fig. 1 e]). The patient was discharged 3 days after the operation without any complications.

Compared with ESD, the TA-EMR method could reduce technical difficulty and save operation time while ensuring complete resection. For flat lesions, the TA-EMR technique was more effective in ensuring negative horizontal margins than previous reports of one AWC-assisted underwater EMR [1].

Endoscopy_UCTN_Code_TTT_1AO_2AC

Publikationsverlauf

Artikel online veröffentlicht:
03. Februar 2023

• Reference

• 1 Deng C, Wu S, Liao L. et al. Use of a self-made additional working channel for underwater endoscopic mucosal resection of a rectal neuroendocrine tumor. Endoscopy 2022; 54: E790-E791