Description:
This video demonstrates the ESD technique used to remove a type 0-IIa+IIc 15 mm early gastric cancer of the fundus in a 79 year-old male patient.
The procedure took place in the operating theatre, under deep sedation, with back-up surgical team available.
Preoperative endoscopy included contrast chromoscopy with 0.2% indigo carmine dye together with Magnifying Endoscopy (115X by Olympus GIFQ160Z). Histological assessment confirmed the lesion as High Grade Non Invasive Neoplasia.
The key steps of the ESD technique are:
- Marking
- Submucosal injection (saline and adrenaline solution 1:20000 stained with indigo carmine)
- Circumferential incision around the lesion
- Submucosal dissection
- Inspection of the ulcer site and coagulation of borders and visible vessels.
An adequate submucosal cushion is essential to reduce the risk of thermal injury to the muscular layer, perforation and haemorrhage.
The lesion was located in the fundus, immediately below the gastro-esophageal junction, along the lesser curve.
Magnification reveals small and irregular pits and vessels and chromoscopy clearly shows the margins of the lesion.
After confirming the lesion, the border between the lesion and the normal mucosa is marked by the Hook-knife (Olympus Medical Systems Corp., Tokyo, Japan) at least 5 mm away from its lateral margins.
The electrosurgical unit (Olympus Endocut Generator PSD-60) is set at Endocut Mode, Effect 3, with an output power of 60 to 80 Watt for Cutting and 20 Watt Forced for Coagulation.
Lifting solution is injected into the submucosal layer to create a cushion between the lesion and the muscular layer.
Once the lesion has been raised, a circumferential incision around the lesion is performed using the Hook-knife (Olympus Medical Systems Corp., Tokyo, Japan).
Lifting solution is injected into the submucosal layer to create a cushion between the lesion and the muscular layer.
The submucosal dissection is then performed using the It-knife starting from the proximal margin. Tiny repeated injections of cushion solution through the incised mucosa help identifying the submucosal layer for a constant control of depth and direction of the cutting.
Scope retroversion is required to approach and dissect the distal margin of the lesion.
Minor intra-procedural bleeding can be immediately treated with the Coagrasper forceps (Olympus Medical Systems Corp., Tokyo, Japan).
An attachment cap can be used during the procedure in order to get better counter-traction and facilitate the dissection.
The procedure is then terminated with successful en bloc excision and retrieval of the lesion.
Careful inspection of the ulcer site and coagulation of the borders and of visible vessels is routinely performed. Sucralfate is also flushed over the ulcer crater to form a protective coating.
Once retrieved, the specimen is fixed orientated on a board and sectioned in 2-mm intervals parallel to the closest resection margin to assess both lateral and vertical margins.
Histology revealed a well-differentiated (G1) intramucosal adenocarcinoma of intestinal type, with horizontal and vertical margins free of tumor.(1)
The patient had plan x-ray to exclude perforation, and was allowed a liquid diet 48 hours after the procedure. PPI were routinely administered for 1 month.
At nearly 5-year follow-up, the patient is alive and free of disease.
1. Coda S. et al. A Western single-center experience with endoscopic submucosal dissection for early gastrointestinal cancers. Gastric Cancer 2010; 13(4): 258-263.
Contributed By:
Sergio Coda, MD, PhD, Imperial College London, UK
Paolo Trentino, MD, University of Rome
