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CC BY 4.0 · Endoscopy 2024; 56(S 01): E132-E133
DOI: 10.1055/a-2233-2914
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First report of gastric endoscopic intermuscular dissection

Edward J. Despott
1   Royal Free Unit for Endoscopy, The Royal Free Hospital, University College London Institute for Liver and Digestive Health, London, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN171090)
,
Laura A. Lucaciu 
1   Royal Free Unit for Endoscopy, The Royal Free Hospital, University College London Institute for Liver and Digestive Health, London, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN171090)
,
Alberto Murino
1   Royal Free Unit for Endoscopy, The Royal Free Hospital, University College London Institute for Liver and Digestive Health, London, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN171090)
,
Alessandro Rimondi 
1   Royal Free Unit for Endoscopy, The Royal Free Hospital, University College London Institute for Liver and Digestive Health, London, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN171090)
,
Kenneth Binmoeller
2   Interventional Endoscopy, California Pacific Medical Center, San Francisco, United States (Ringgold ID: RIN7153)
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Although endoscopic intermuscular dissection (EID) has been used successfully to treat rectal pathology [1], its application in stomach procedures has not been reported. EID involves the dissection of the circular layer from the longitudinal layer of the muscularis propria to achieve a clear vertical dissection margin [2] [3].

A 43-year-old woman was referred to our center for endoscopic resection of a 15-mm type 1 neuroendocrine tumor (NET) located in the lower gastric body ([Fig. 1]). Saline immersion therapeutic endoscopy-facilitated EID was performed under general anesthesia ([Video 1]). A gastroscope (GIF-1TH-190; Olympus, Tokyo, Japan) with a water jet was used for saline exchange and aspiration of bubbles or gas. EID was performed using a 1.5-mm ball-tip knife (FlushKnife BTS; Fujifilm, Tokyo, Japan) and a prototype partially circumferential cap attachment, designed to provide tissue counter-traction, a wide endoscopic field of view, and facilitate instrument passage without friction (Micro-tech, Nanjing, China) ([Video 1]). Despite previous endoscopic ultrasound having shown the NET to be entirely submucosal, our procedure revealed it to be adherent to the muscularis propria, necessitating EID to achieve a tumor-free deep resection margin. The resection site was closed in two layers using through-the-scope clips (Resolution Clip; Boston Scientific, Natick, Massachusetts, USA). Histopathological analysis confirmed the tumor to be a type 1 gastric NET, arising on a background of chronic atrophic gastritis with enterochromaffin-like cell hyperplasia ([Fig. 2], [Fig. 3]), with no lymphovascular or perineural invasion (World Health Organization Grade 2), and an R0 resection was achieved. Following our protocol, the patient was discharged after 72 hours without any adverse events.

Zoom Image
Fig. 1 Neuroendocrine tumor adherent to the inner oblique layer of the muscularis propria.
Saline immersion therapeutic endoscopy–facilitated endoscopic intermuscular dissection (EID) of a type 1 neuroendocrine tumor (NET) located in the lower gastric body.Video 1

Zoom Image
Fig. 2 Histopathological analysis of hematoxylin and eosin-stained section demonstrating a grade 2 neuroendocrine tumor (black arrow). The green arrow indicates the inner oblique layer of gastric muscularis propria. Dissection only above the interrupted red line would have resulted in an R1 (noncurative) resection.
Zoom Image
Fig. 3 Histopathological analysis of chromogranin-stained section demonstrating a grade 2 neuroendocrine tumor (black arrow) invading the inner oblique layer of the muscularis propria (green arrow). Dissection above the interrupted red line would have resulted in an R1 (non-curative) resection.

This first report of gastric EID demonstrates the feasibility of this technique for gastric pathology when deeper excision margins are required to achieve R0 resection. Further studies on the wider application of gastric EID in clinical practice would be worthwhile. Furthermore, the use of saline immersion therapeutic endoscopy is crucial for ensuring clear visualization and buoyancy during EID [4].

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Conflict of Interest

Edward J. Despott was a consultant for Boston Scientific and Ambu. He has received academic grants and speaker honoraria from Fujifilm, Aquilant Endoscopy, Norgine, and Olympus. Laura A. Lucaciu and Alessandro Rimondi have no conflicts of interest. Alberto Murino was a consultant for Boston Scientific and GI supply. He has received academic grants from Fujifilm, Aquilant Endoscopy, Norgine, and Olympus. Kenneth Binmoeller is the inventor of the visor cap.

  • References

  • 1 Rahni D, Toyonaga T, Ohara Y. et al. First reported case of per anal endoscopic myectomy (PAEM): a novel endoscopic technique for resection of lesions with severe fibrosis in the rectum. Endosc Int Open 2017; 5: E146-E150
    Thieme ConnectPubMedSearch in Google Scholar
  • 2 Moons LMG, Bastiaansen BAJ, Richir MC. et al. Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum: a new endoscopic approach. Endoscopy 2022; 54: 993-998
    Thieme ConnectPubMedSearch in Google Scholar
  • 3 Libânio D, Pimentel-Nunes P, Bastiaansen B. et al. Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) technical review. Endoscopy 2023; 55: 361-389
    Thieme ConnectPubMedSearch in Google Scholar
  • 4 Despott EJ, Murino A. Saline-immersion therapeutic endoscopy (SITE): an evolution of underwater endoscopic lesion resection. Dig Liver Dis 2017; 49: 1376
    CrossrefPubMedSearch in Google Scholar

Correspondence

Edward J. Despott, MD, MD(Res)
University College London Institute for Liver & Digestive Health, 8th Floor South Offices, The Royal Free Hospital & UCL School of Medicine Royal Free London NHS Foundation Trust
Pond Street, Hampstead, London NW3 2QG
United Kingdom   

Publication History

Article published online:
07 March 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

  • References

  • 1 Rahni D, Toyonaga T, Ohara Y. et al. First reported case of per anal endoscopic myectomy (PAEM): a novel endoscopic technique for resection of lesions with severe fibrosis in the rectum. Endosc Int Open 2017; 5: E146-E150
    Thieme ConnectPubMedSearch in Google Scholar
  • 2 Moons LMG, Bastiaansen BAJ, Richir MC. et al. Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum: a new endoscopic approach. Endoscopy 2022; 54: 993-998
    Thieme ConnectPubMedSearch in Google Scholar
  • 3 Libânio D, Pimentel-Nunes P, Bastiaansen B. et al. Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) technical review. Endoscopy 2023; 55: 361-389
    Thieme ConnectPubMedSearch in Google Scholar
  • 4 Despott EJ, Murino A. Saline-immersion therapeutic endoscopy (SITE): an evolution of underwater endoscopic lesion resection. Dig Liver Dis 2017; 49: 1376
    CrossrefPubMedSearch in Google Scholar

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Zoom Image
Fig. 1 Neuroendocrine tumor adherent to the inner oblique layer of the muscularis propria.
Zoom Image
Fig. 2 Histopathological analysis of hematoxylin and eosin-stained section demonstrating a grade 2 neuroendocrine tumor (black arrow). The green arrow indicates the inner oblique layer of gastric muscularis propria. Dissection only above the interrupted red line would have resulted in an R1 (noncurative) resection.
Zoom Image
Fig. 3 Histopathological analysis of chromogranin-stained section demonstrating a grade 2 neuroendocrine tumor (black arrow) invading the inner oblique layer of the muscularis propria (green arrow). Dissection above the interrupted red line would have resulted in an R1 (non-curative) resection.