Utility of image-enhanced magnifying endoscopy and traction wire for a successful endoscopic submucosal dissection in early gastric cancer

Characterizing tumor extent in early gastric cancer (EGC) is difficult and magnifying endoscopy with narrow-band imaging (M-NBI) is often necessary [1] [2]. Submucosal dissection of large lesions via endoscopic submucosal dissection (ESD) is a time-consuming task. Here, we report the benefit of the traction wire (ERD-TW35; Medtronic, Minneapolis, Minnesota, USA) [3] [4] [5] as a unique technique for ESD.

An 80-year-old man with EGC was referred to us. Endoscopy revealed a depressed lesion on the greater curvature of the antrum. Subsequently, we diagnosed the patient with depressed intramucosal EGC and performed ESD. The depressed lesion was marked circumferentially ([Fig. 1], [Video 1]), and M-NBI revealed that the lesion had extended to the proximal wide area, as evident by the presence of mucosae with irregular microvascular patterns ([Fig. 2]). M-NBI with 1.5 % acetic acid spraying demonstrated irregular microsurface patterns, and additional markings were added around the new area.

Fig. 1 Endoscopy revealed the circumferential markings around the depressed lesion.

Video 1 Endoscopic submucosal dissection with a traction wire device for a case of early gastric cancer.

Fig. 2 Magnifying endoscopy with narrow-band imaging revealed an irregular microvascular pattern on the mucosa (arrows) outside the markings.

ESD using the traction wire was performed to retrieve larger margins. Following circumferential mucosal incision, a primary clip with traction wire was deployed at the oral margin. The wire loop was hooked using the second clip and placed on the distal margin ([Fig. 3]). Appropriate tension was obtained attributed to the curved shape of the traction wire, exposing the submucosa during dissection ([Fig. 4]). This facilitated submucosal dissection, and the procedure lasted less than 10 min after deploying the traction wire. Finally, the lesion was resected en bloc, and the specimen measured 62 × 50 mm, with a lesion size of 46 × 35 mm ([Fig. 5]). Histopathology revealed a moderately differentiated adenocarcinoma confined to the shallow submucosa with negative margins.

Fig. 3 Additional markings were performed around the proximal extension of the lesion.

Fig. 4 The traction wire was deployed at the oral margin and the distal margin of the lesion.

Fig. 5 The lesion was resected en bloc and histopathology revealed moderately differentiated adenocarcinoma confined to the shallow submucosa with negative margins.

In conclusion, the image-enhanced magnification provided its utility in determining the accurate resection margins for the gastric cancer. Moreover, the traction wire was a useful device that facilitated submucosal dissection for the large lesion in a timely manner.

Endoscopy_UCTN_Code_TTT_1AO_2AC

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Kadowaki S, Tanaka K, Toyoda H. et al. Ease of early gastric cancer demarcation recognition: a comparison of four magnifying endoscopy methods. J Gastroenterol Hepatol 2009; 24: 1625-1630
• 2 Hu Y, Chen X, Hendi M. et al. Diagnostic ability of magnifying narrow-band imaging for the extent of early gastric cancer: a systematic review and meta-analysis. Gastroenterol Res Pract 2021;
• 3 Aslam SP, Abdelrahim M, Subramaniam S. et al. Feasibility and safety of using a novel traction wire for endoscopic submucosal dissection of challenging gastrointestinal neoplasia. Endoscopy 2022; 54: E606-E607
• 4 Ishii H, Fukuda H, Hayashi Y. et al. A traction wire facilitates the pocket-creation method for endoscopic submucosal dissection in the cecum. Endoscopy 2022; 54: E776-E777
• 5 Tanaka K, Kido K, Sawai S. et al. Endoscopic submucosal dissection with a novel traction wire for esophageal cancer in the cervical esophagus. Endoscopy 2022; 54: E1055-E1056

Publikationsverlauf

Artikel online veröffentlicht:
11. April 2023