Endoscopy 2022; 54(11): E652-E653
DOI: 10.1055/a-1732-7113
E-Videos

Novel approach to endoscopic submucosal dissection using an additional working channel: a case report

Francesco Azzolini
Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
,
Francesco Vito Mandarino
Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
,
Alberto Barchi
Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
,
Paolo Biamonte
Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
,
Maria Napolitano
Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
,
Dario Esposito
Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
,
Silvio Danese
Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
› Author Affiliations
 

A 72-year-old man underwent endoscopic submucosal dissection (ESD) of a 7-cm mixed-type laterally spreading tumor of the distal rectum, histologically defined as intramucosal adenocarcinoma. During subsequent surveillance, a 4-cm nonpolypoid lesion was detected on the resection scar ([Fig. 1]). We performed a novel technique for ESD, using an external additional working channel (AWC; Ovesco Endoscopy, Tübingen, Germany), called “ESD+,” to eradicate the recurrent lesion ([Fig. 1, ] [Fig. 2, ] [Fig. 3]).

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Fig. 1 Nonpolypoid lesion on the resection scar following endoscopic submucosal dissection (ESD) of a mixed-type laterally spreading tumor of the rectum, marked for ESD using an external additional working channel.
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Fig. 2 Additional working channel assembled over the scope.
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Fig. 3 Closer view of the additional working channel on the tip of the scope.

The procedure was conducted using a standard gastroscope. A HybridKnife I-Type (Erbe) dissector with saline solution (mixed with indigo carmine and adrenaline) as lifting fluid was used for the marking, incision, and partial dissection of the lesion. Subsequently, rescue forceps were introduced via the additional working channel to mobilize the lesion flap ([Fig. 4]) and complete the dissection ([Fig. 5]). This procedure allowed satisfactory exposure of the submucosal layer, ensuring safety and saving time in the resection of the whole lesion. The dissection was completed without complications ([Video 1]).

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Fig. 4 The rescue forceps helps the exposure of submucosal layer.
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Fig. 5 The resected lesion.

Video 1 Endoscopic submucosal dissection with an external additional working channel (“ESD+”) to treat a recurrent lesion of the rectum.


Quality:

While the use of rescue forceps via an additional working channel is widely recognized in the literature as a technique for endoscopic mucosal resection (EMR+) [1] [2], the ESD+ technique has been reported in vivo in only one recent case series, showing good results in terms of the timing and suitability of the procedure [3].

From our experience, an external working channel applied over the scope is a low-cost and safe device, and its use could improve the duration and technical feasibility of dissections of even quite large lesions without the need for a double-channel scope.

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Competing interests

S. Danese has served as a speaker, consultant and advisory board member for Schering-Plough, AbbVie, Actelion, Alphawasserman, AstraZeneca, Cellerix, Cosmo Pharmaceuticals, Ferring, Genentech, Grunenthal, Johnson and Johnson, Millennium Takeda, MSD, Nikkiso Europe GmbH, Novo Nordisk, Nycomed, Pfizer, Pharmacosmos, UCB Pharma and Vifor.


Corresponding author

Alberto Barchi, MD
Division of Gastroenterology and Gastrointestinal Endoscopy
Department of Experimental Oncology
IRCCS San Raffaele Scientific Institute
Vita-Salute San Raffaele University
Via Olgettina, 60
20136 Milan
Italy   

Publication History

Article published online:
04 February 2022

© 2022. Thieme. All rights reserved.

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Zoom Image
Fig. 1 Nonpolypoid lesion on the resection scar following endoscopic submucosal dissection (ESD) of a mixed-type laterally spreading tumor of the rectum, marked for ESD using an external additional working channel.
Zoom Image
Fig. 2 Additional working channel assembled over the scope.
Zoom Image
Fig. 3 Closer view of the additional working channel on the tip of the scope.
Zoom Image
Fig. 4 The rescue forceps helps the exposure of submucosal layer.
Zoom Image
Fig. 5 The resected lesion.