Endoscopic submucosal dissection (ESD) for gastric tumors is performed worldwide.
When vascularized lesions are treated, hematoma in the submucosal layer is sometimes
encountered during dissection. The presence of submucosal fibrosis and hematoma often
makes dissection very difficult because identifying the correct submucosal tissue
plane is almost impossible despite attempts at washing using the scope’s water jet
function. Red dichromatic imaging (RDI; Dual Red Imaging) is a recently released novel
image-enhanced endoscopic technology (Olympus Medical Systems, Tokyo, Japan) [1]
[2]
[3]
[4]. We report a case in which RDI helped identify submucosal fibrous tissue in the
submucosal layer with hematoma during gastric ESD.
A 72-year-old man with a gastric tumor was referred to our hospital. ESD was performed
using an electrosurgical knife (IT2 knife; Olympus Medical Systems) and therapeutic
gastroscope (GIF-H290 T with EVIS X1 video system; Olympus Medical Systems). A circumferential
incision was made and the submucosal layer subsequently dissected. However, the submucosal
injection caused bleeding in the submucosal layer, leading to submucosal hematoma
([Video 1]; [Fig. 1]). In this situation, identifying the submucosal fibrous tissue for dissection under
white light ([Video 1]; [Fig. 2 a]) was difficult. The white light imaging was then switched to RDI, and the submucosal
fibrous tissue could be visualized more clearly ([Fig. 2 b]). The submucosal layer was dissected and the tumor finally resected en bloc.
Video 1 Endoscopic submucosal dissection for gastric tumor in a 72-year-old man. The submucosal
fibrous tissue could be identified more clearly in the submucosal layer with hematoma
using red dichromatic imaging.
Fig. 1 Endoscopic submucosal dissection for gastric tumor in a 72-year-old man. Hematoma
in the submucosal layer was caused by the submucosal injection.
Fig. 2 a Endoscopic image of the submucosal layer with severe hematoma observed using white
light. b Endoscopic image of the submucosal layer with severe hematoma observed using red
dichromatic imaging (RDI). The bleeding was visualized as yellow using RDI. The submucosal
fibrous tissue was identifiable through the hematoma.
In this case, the submucosal fibrous tissue was identified because it showed whiter
using RDI than under normal white light imaging ([Fig. 3]), and the bleeding was visualized as yellow on RDI. Thus, the submucosal fibrous
tissue could be identified through the hematoma, and was dissected despite the presence
of the hematoma. Another advantage of RDI is that it keeps the endoscopic view clearer
during ESD with submucosal fatty tissue [5]. We believe that RDI is useful for dissecting submucosal fibrous tissue in the submucosal
layer with hematoma during gastric ESD.
Fig. 3 a Endoscopic image of the submucosal layer with severe hematoma observed using white
light. b Endoscopic image of the submucosal fibrous tissue observed using RDI. The submucosal
fibrous tissue showed whiter and clearer in the submucosal layer with hematoma.
Endoscopy_UCTN_Code_CCL_1AB_2AD_3AF
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