Endoscopic submucosal dissection by transnasal endoscope for esophageal cancer with pharyngoesophageal anastomotic stricture after total pharyngo-laryngo-esophagectomy

Patients with squamous cell carcinoma (SCC) of the head and neck often develop secondary esophageal carcinomas. We describe a successful case of endoscopic submucosal dissection (ESD) using a transnasal endoscope to treat a patient with esophageal cancer with a pharyngoesophageal anastomotic stricture after total pharyngo-laryngo-esophagectomy (TPLE).

A 60-year-old man was referred to our division for treatment of esophageal cancer. The patient had undergone TPLE for advanced hypopharyngeal cancer 5 years previously, and endoscopy revealed a flat lesion in the lower third of the esophagus ([Fig. 1 a, b]). The patient had a pharyngoesophageal anastomotic stricture after the TPLE that could not be passed using a conventional endoscope ([Fig. 1 c]). Endoscopic balloon dilation was not possible because of the presence of a voice prosthesis ([Fig. 1 d]). Recently, an improved transnasal endoscope, the EG-L580NW (Fujifilm, Tokyo, Japan), has become available, with a 5.8-mm outer diameter and a 2.4-mm forceps diameter ([Fig. 2 a]) [1]. An ultrathin needle-type device (Souten; Kaneka Medics, Tokyo, Japan) and hemostasis forceps (Raicho; Kaneka Medics, Tokyo, Japan) can be used with this endoscope ([Fig. 2 b, c]) [2]. Thus, we performed ESD using a transnasal endoscope to treat the esophageal cancer ([Video 1]).

Fig. 1 a – d A 60-year-old man referred for treatment of esophageal cancer 5 years after undergoing total pharyngo-laryngo-esophagectomy (TPLE) for advanced hypopharyngeal cancer. a Blue laser imaging shows a brownish area in the lower third of the esophagus. b After chromoendoscopy using Lugol’s iodine, markers were placed 2 – 3 mm outside of the lesion margins. c Pharyngoesophageal anastomotic stricture after the TPLE (arrow). d A voice prosthesis had been used to restore the voice (arrow).

Fig. 2 a The EG-L580NW (Fujifilm, Tokyo, Japan) has an instrument channel with a 2.4 – mm inner diameter. b The Souten ultrathin needle-type device has a diameter of 2.35 mm at the insertion sheath. c The Raicho hemostasis forceps has a diameter of 2.3 mm at the insertion sheath.

Video 1 Endoscopic submucosal dissection by transnasal endoscope for esophageal cancer with pharyngoesophageal anastomotic stricture after total pharyngo-laryngo-esophagectomy.

Circumferential incisions were made using the Souten with Endo Cut I mode (VIO 300D; Erbe, Tübingen, Germany; effect 2, duration 2, interval 2) ([Fig. 3 a, b]). To control bleeding, the Raicho forceps was used in soft coagulation mode at 50 W. Submucosal dissection was performed using the Souten and swift coagulation mode (effect 3, 30 W) ([Fig. 3 c]). Finally, en bloc resection was achieved without injury to the muscularis propria ([Fig. 3 d]). Histological examination revealed R0 resection of the squamous cell carcinoma, which was limited to the epithelium ([Fig. 4]).

Fig. 3 a A caudal incision was performed. b Circumferential incisions were made using the Souten. c Submucosal dissection was performed. d En bloc resection was achieved without causing injury to the muscularis propria.

Fig. 4 a Resected specimen after iodine staining. b Histology shows esophageal squamous cell carcinoma limited to the epithelium.

Esophageal ESD using a transnasal endoscope was useful in treating esophageal cancer with an anastomotic stricture that could not be passed using a conventional endoscope.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Suzuki T, Kitagawa Y, Nankinzan R. et al. Early gastric cancer diagnostic ability of ultrathin endoscope loaded with laser light source. World J Gastroenterol 2019; 25: 1378-1386
• 2 Minato Y, Sakai E, Ohata K. Conscious transnasal hybrid endoscopic submucosal dissection enables safe and painless en bloc resection in elderly patients with early gastric cancer. VideoGIE 2019; 4: 157-158

Publication History

Article published online:
12 May 2020