Endoscopy 2022; 54(11): E646-E647
DOI: 10.1055/a-1731-7268
E-Videos

Clip-with-line traction suture method with adaptation of the mucosal flap in a large transmural defect after submucosal tunneling endoscopic resection of a submucosal tumor at the esophagogastric junction

1   AUSL Bologna, Bologna, Italy
,
2   Hospital Senhora da Oliveira, Guimarães, Portugal
,
Horst Neuhaus
3   Evangelisches Krankenhaus, Düsseldorf, Germany
,
3   Evangelisches Krankenhaus, Düsseldorf, Germany
,
Christian Gerges
3   Evangelisches Krankenhaus, Düsseldorf, Germany
› Author Affiliations
 

Submucosal tunneling endoscopic resection (STER) [1] is a demanding technique that can potentially lead to serious complications [2] [3]. A 51-year-old patient with solid food dysphagia underwent an esophagogastroduodenoscopy, which showed a subepithelial mass just below the esophagogastric junction (EGJ). Endoscopic ultrasound confirmed a well-demarcated 30 × 24 mm subepithelial mass attached to the muscularis propria, predominantly hypoechogenic but with some hyperechogenic foci.

STER was performed using a Hybrid-Knife I-Type (Endocut-Q, Setting 2-3-3, Vio 300D; ERBE Elektromedizin, Tübingen, Germany) under low-flow carbon dioxide insufflation ([Video 1]). A 2-cm longitudinal mucosal access was created in the esophagus, 4 cm proximal to the EGJ, and a submucosal tunnel was created until the submucosal lesion was found in the deep posterior muscularis propria layer ([Fig. 1 a, b]). To avoid tumor capsule damage, the muscular layer had to be opened. Owing to the difficult position of the lesion, the scope had to be at maximum retroflexion for deep muscular layer preparation. However, a large mucosal tear was observed, caused by the traction exerted by the scope during the procedure, thus causing a large transmural perforation ([Fig. 1 c]).

Video 1 Clip-with-line traction suture method with adaptation of the mucosal flap in a large transmural defect after submucosal tunneling endoscopic resection.


Quality:
Zoom Image
Fig. 1 Schema of submucosal tunneling endoscopic resection technique. a Submucosal tumor. b Submucosal tunneling. c Muscular layer dissection and evidence of a mucosal tear.

After tumor removal ([Fig. 2 a]), a 16-mm hemostatic clip (Lockado-Clip, Microtech Europe, Duesseldorf, Germany) with medical floss was placed in the proximal margin of the mucosal flap. The floss was pulled to lift the mucosal flap upwards to cover the defect. Subsequently the tear was closed by attaching the side margins of the flap to the surrounding mucosa using 20-mm hemostatic clips (Lockado-Clip, Microtech Europe, Duesseldorf, Germany) ([Fig. 2 b, c]).

Zoom Image
Fig. 2 Closure of the tear. a Complete resection and tumor removal. b Clip-with-line traction suture method. c Complete defect closure by mucosal flap and tunnel entrance closure.

Broad-spectrum antibiotic therapy was given. The following day, an esophagram confirmed no leakage and a liquid diet was started. After follow-up endoscopy on Day 3, the patient received a semi-liquid diet and was then discharged on a regular diet. There were no complications during the follow-up. Histology showed a leiomyoma.

The clip-with-line traction suture method was previously described to align mucosal margins to allow easier defect closure after submucosal dissection [4]. In the current case, it was used to close the mucosal flap over the tear.

Endoscopy_UCTN_Code_CPL_1AH_2AJ

Endoscopy E-Videos
https://eref.thieme.de/e-videos

Endoscopy E-Videos is an open 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. Processing charges apply (currently EUR 375), discounts and wavers acc. to HINARI are available.

This section has its own submission website at https://mc.manuscriptcentral.com/e-videos


#

Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Annalisa Cappello, MD
AUSL Bologna
Department of Gastroenterology and Interventional Endoscopy
Largo Nigrisoli 2
40133 Bologna (BO)
Italy   

Publication History

Article published online:
04 February 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Schema of submucosal tunneling endoscopic resection technique. a Submucosal tumor. b Submucosal tunneling. c Muscular layer dissection and evidence of a mucosal tear.
Zoom Image
Fig. 2 Closure of the tear. a Complete resection and tumor removal. b Clip-with-line traction suture method. c Complete defect closure by mucosal flap and tunnel entrance closure.