Double-endoscope assisted endoscopic submucosal dissection for treating gastric neuroendocrine tumor.

A middle-aged man was found to have a solitary lesion about 5 mm in diameter on the greater curvature of the lower gastric body during routine endoscopic examination ([Fig. 1 a]). Biopsy pathology plus immunohistochemistry reported a neuroendocrine tumor G2. A double-endoscope assisted endoscopic submucosal dissection (ESD) procedure was used to remove the tumor ([Video 1]).

Fig. 1 a Submucosal lesion on the greater curvature of the lower gastric body with post-biopsy scar on covering mucosa. b Cautery markings and submucosal injection around the tumor. c Initial incision of covering mucosa on the oral side of the tumor. d Traction of the covering mucosa by a snare controlled by a second endoscope. e Clean wound surface after tumor removal. f Resected tumor specimen.

Video 1 Double-endoscope assisted endoscopic submucosal dissection for treating gastric neuroendocrine tumor.

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The procedure began with cautery markings around the tumor using a dual knife, followed by submucosal injection ([Fig. 1 b]) and incision of the oral side of the covering mucosa ([Fig. 1 c]). In order to facilitate subsequent tumor dissection, a second endoscope equipped with a snare was applied to provide additional traction on the covering mucosa to aid in submucosal dissection ([Fig.1 d]). The second endoscope does not need its own light source since the main endoscope can guide the snare to grasp the mucosa and the rest is simply to maintain traction. The snare can be pulled or pushed by the second endoscope in multiple directions, providing better exposure than the widely used “clip-and-thread” method, where the clip attached to the mucosa can be pulled only toward the oral side.

After tumor removal, the wound surface was carefully examined for potential perforation; electric forceps were used to coagulate visible bleeding ([Fig. 1 e, f]). The whole procedure took only about 20 minutes thanks to effective exposure. To our knowledge, this is the second report of endoscopic resection of a gastric submucosal tumor aided by a second endoscope [1] and the first report of such a procedure without a second light source.

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• Reference

• 1 Çolak Ş, Gürbulak B, Çakar E. et al. Resection of mucosal and submucosal gastrointestinal lesions and a double endoscope experience. JSLS 2019; 23: e2018.00096