Wide-tunnel endoscopic submucosal dissection with clip-and-line traction for large circumferential esophageal neoplasm

Endoscopic submucosal dissection (ESD) has become the main method for management of superficial esophageal lesions [1]. However, it remains technically challenging and time-consuming for circumferential lesions [2]. The strategies reported for circumferential diseases have operational complexity [2] [3]. Herein, we present an ESD method involving a single, wide tunnel and clip-and-line traction for resection of a large circumferential esophageal neoplasm.

A 68-year-old man with a large circumferential esophageal lesion was referred to our hospital. Magnifying chromoendoscopy suggested a noninvasive squamous cell carcinoma, and biopsy confirmed a high grade intraepithelial neoplasia. Computed tomography detected no nodal or distal metastases. Under multidisciplinary discussion and the patient’s informed consent, esophageal ESD was chosen ([Video 1]).

Video 1 Single-tunnel endoscopic submucosal dissection with clip-and-line traction applied to two sites for a large circumferential esophageal neoplasm.

The patient underwent general anesthesia. A dual knife was used during the whole procedure. First, after lesion marking, anal and oral circumferential incisions were performed successively ([Fig. 1 a–c]). Second, after submucosal injection, a single, wide tunnel was created from the oral side to the anal incision ([Fig.1 d]). The undissected mucosa retracted, reducing the remaining lesion and facilitating the ongoing procedure. Third, a single clip-and-line traction system was applied to two sites on the oral side of the lesion, facilitating the ESD procedure with adequate exposure of the submucosal layer ([Fig. 1 e, f]). Finally, the procedure was successfully performed, with en bloc resection and a procedure time of 96 minutes ([Fig. 1 g, h]). There were no significant intraoperative adverse events. The specimen showed a squamous cell carcinoma, with invasion of the muscularis mucosa and negative margins.

Fig. 1 Endoscopic views during the single-tunnel endoscopic submucosal dissection with clip-and-line traction applied to two sites on the oral side of the lesion. a A circumferential esophageal lesion. b Circumferential incision of the anal side of the lesion. c Circumferential incision of the oral side of the lesion. d Creation of a single, wide tunnel. e A single clip-and-line system was applied to two sites on the oral side for traction. f With the undissected mucosa retracted, submucosal dissection was performed with adequate exposure of the remaining submucosal layer. g The artificial ulcer after endoscopic submucosal dissection. h The dissected mucosa.

The patient received oral glucocorticoid treatment postoperatively. He developed mild stenosis after 5 weeks, and to date has received three endoscopic dilations up to 13 mm. No recurrence was found at 2 months’ follow-up.

In conclusion, ESD with single, wide tunnel and clip-and-line traction applied to two sites on the oral side of the lesion can facilitate safe and fast resection of large circumferential esophageal neoplasms.

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Competing interests

The authors declare that they have no conflict of interest.

^* Co-first authors

• References

• 1 Ishihara R, Arima M, Iizuka T. et al. Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer. Dig Endosc 2020; 32: 452-493
• 2 Fraile-Lopez M, Parra-Blanco A. Double-tunnel circumferential endoscopic submucosal dissection with double clip-band-line traction for an esophageal squamous neoplasm. Endoscopy 2020; 52: E303-E305
• 3 Schaefer M, Albouys J, Charissoux A. et al. Circumferential esophageal endoscopic submucosal dissection thanks to the tunnel + clip strategy: four tunnels to facilitate the procedure. Endoscopy 2018; 50: E350-E351

Publication History

Article published online:
15 February 2022