Endoscopy 2014; 46(S 01): E204-E205
DOI: 10.1055/s-0034-1365390
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Double-tunnel endoscopic submucosal tunnel dissection for circumferential superficial esophageal neoplasms

Yaqi Zhai
Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
,
Enqiang Linghu
Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
,
Huikai Li
Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
› Author Affiliations
Further Information

Corresponding author

Enqiang Linghu, MD
Fuxing Road 28
Dept. of Gastroenterology and Hepatology
PLA General Hospital
Beijing
China   
Fax: +86-10-66937485   

Publication History

Publication Date:
22 April 2014 (online)

 

Endoscopic submucosal tunnel dissection (ESTD) was first introduced by us as a new strategy for rapid resection of large esophageal neoplasms [1]. However, for circumferential superficial esophageal neoplasms (CSENs), an obscured view and poor submucosal lifting have been experienced during lateral resection of the final one-third of the circumference. In our early experience using single-tunnel ESTD to treat four patients with CSENs, the mean operation time was 382.5 minutes and one patient experienced a perforation. To counteract the problems with this technique, we have now successfully performed a double-tunnel ESTD procedure on a patient with an 8-cm CSEN.

A 66-year-old man was referred for resection of an 8-cm CSEN, at about 28 cm to 36 cm from the incisors ([Fig. 1]; [Video 1]). After marking the margin of the lesion, successive circular incisions were made at the anal and oral margins using a dual knife (KD-650L; Olympus, Tokyo, Japan) and an insulated-tip knife (KD-611L; Olympus) ([Fig. 2 a]). The first submucosal tunnel was created in the oral to anal direction using a triangular knife (KD-640L; Olympus), with endoscopic hemostasis of visible vessels or active bleeding being actively performed, either with a knife or with a hot forceps. A second tunnel was then created, running in the opposite direction to the first, using the same technique ([Fig. 2 b]). Finally, the narrow borders between the two tunnels were easily resected ([Fig. 2 c]), which allowed for complete removal of the lesion ([Fig. 3]). To prevent postoperative stricture, a 14-cm retrievable, fully-covered esophageal stent (CZES-II; Sigma, Huaian, China) was placed after preventive coagulation of the artificial ulcer had been performed ([Fig. 4]).

Zoom Image
Fig. 1 Chromoendoscopy with iodine staining showing a superficial esophageal cancer (0-IIb) that discontinuously occupied nearly the whole circumference of the esophagus, at about 28 cm to 36 cm from the incisors.


Quality:
Double-tunnel endoscopic submucosal tunnel dissection being performed for a circumferential superficial esophageal neoplasm.

Fig. 2 Endoscopic view showing: a circular incisions at the anal and oral margins of the lesion that were made with a dual knife and an insulated-tip knife; b the two submucosal tunnels that were created by submucosal dissection with a triangular knife; c the narrow borders left following completion of the two tunnels, which could then be easily resected.

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Fig. 3 The specimen that was retrieved (approximately 60 mm in length) and is shown covering a 5-mL syringe.
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Fig. 4 The 14-cm retrievable, fully-covered esophageal stent positioned in the esophagus after preventive coagulation of the artificial ulcer had been performed.

The whole operation took 97 minutes and the patient’s recovery was uneventful. Histopathological examination revealed a micro-invasive squamous carcinoma limited to the lamina propria mucosae without vascular invasion, and the resection margins were free of cancer.

Recently, there have been an increasing number of reports on the use of ESTD for large esophageal neoplasms [2] [3], which have also described the advantage this technique has over endoscopic submucosal dissection (ESD), namely improved speed of dissection [4]. Compared with the single-tunnel procedure, the double-tunnel ESTD procedure made it easier to dissect most of the esophageal circumference and offered significant improvements in the endoscopic view and the ease of submucosal lifting. This is the first report of the use of double-tunnel ESTD for a CSEN, which appears to be not only safe and feasible, but also more efficient.

Endoscopy_UCTN_Code_TTT_1AO_2AG


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Competing interests: None

  • References

  • 1 Linghu E, Feng X, Wang X et al. Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions. Endoscopy 2013; 45: 60-62
  • 2 Arantes V, Albuquerque W, Freitas Dias CA et al. Standardized endoscopic submucosal tunnel dissection for management of early esophageal tumors (with video). Gastrointest Endosc 2013; 78: 946-952
  • 3 Pioche M, Mais L, Guillaud O et al. Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions. Endoscopy 2013; 45: 1032-1034
  • 4 Zhai Y, Linghu E, Li H et al. Comparison of endoscopic submucosal tunnel dissection with endoscopic submucosal dissection for large esophageal superficial neoplasms. Nan Fang Yi Ke Da Xue Xue Bao 2014; 34: 36-40

Corresponding author

Enqiang Linghu, MD
Fuxing Road 28
Dept. of Gastroenterology and Hepatology
PLA General Hospital
Beijing
China   
Fax: +86-10-66937485   

  • References

  • 1 Linghu E, Feng X, Wang X et al. Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions. Endoscopy 2013; 45: 60-62
  • 2 Arantes V, Albuquerque W, Freitas Dias CA et al. Standardized endoscopic submucosal tunnel dissection for management of early esophageal tumors (with video). Gastrointest Endosc 2013; 78: 946-952
  • 3 Pioche M, Mais L, Guillaud O et al. Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions. Endoscopy 2013; 45: 1032-1034
  • 4 Zhai Y, Linghu E, Li H et al. Comparison of endoscopic submucosal tunnel dissection with endoscopic submucosal dissection for large esophageal superficial neoplasms. Nan Fang Yi Ke Da Xue Xue Bao 2014; 34: 36-40

Zoom Image
Fig. 1 Chromoendoscopy with iodine staining showing a superficial esophageal cancer (0-IIb) that discontinuously occupied nearly the whole circumference of the esophagus, at about 28 cm to 36 cm from the incisors.
Zoom Image
Zoom Image
Zoom Image
Zoom Image
Fig. 3 The specimen that was retrieved (approximately 60 mm in length) and is shown covering a 5-mL syringe.
Zoom Image
Fig. 4 The 14-cm retrievable, fully-covered esophageal stent positioned in the esophagus after preventive coagulation of the artificial ulcer had been performed.