Endoscopic Submucosal Dissection for a Large Gastric Intramucosal Neoplasm

A 64-year-old man presented with complaints of dyspepsia and epigastric burning for 3 months. In view of advanced age, patient underwent esophagogastroduodenoscopy (EGD) elsewhere and was diagnosed to have Helicobacter pylori gastritis and received eradication for the same. Patient was referred to us in view of persistent complaints. Repeat EGD showed erythematous elevated mucosal lesion with no overlying ulceration along the lesser curvature in the body of the stomach—Paris 1s measuring approximately 5 cm in maximum diameter ([Fig. 1], [Video 1]). Narrow band imaging (NBI) (Gastroscope, GIF-XZ1200, Olympus, Tokyo, Japan) showed demarcation line along with irregular microsurface and microvessel pattern ([Figs. 2] and [3], [Video 1]). NBI-targeted biopsy was taken from involved mucosa. Histopathology showed elongated hyperchromatic nuclei with loss of polarity. Focal cribriforming of glands was seen. However, submucosal invasion was not seen suggestive of intramucosal carcinoma.

Fig. 1 White light endoscopy showing elevated erythematous mucosa along the lesser curvature in the body of stomach.

Video 1 0:00–0:10 Introduction of case. 0:10–0:22 Magnification white light endoscopy showing mucosal irregularity. 0:22–0:50 NBI examination showing demarcation line with irregular micro vessel pattern. 0:50–1:22 Marking of gastric lesion done using NBI. 1:22–1:58 Submucosal injection done using normal saline and methylene blue followed by dissection using IT knife. 1:59–2:15 Dissection done along submucosal plane from proximal to distal margin of gastric lesion. 2:16–3:20 Dissection along submucosal plane done from distal margin to proximal margin in retroflexed view. 3:21–3:41 Traction applied using dental floss and hemoclip. 3:42–4:16 Submucosal dissection continued in retroflexed view. 4:17–4:39 Dissection completed using IT knife. 4:40–4:52 Large post-ESD defect seen. Cauterization of visible vessel done using coagrasper. 4:52–5:01 Conclusion and take-home messages. ESD, endoscopic submucosal dissection; NBI, narrow band imaging.

Fig. 2 Narrow band imaging helps in demarcation of lesion.

Fig. 3 Narrow band imaging findings.

Contrast-enhanced computed tomography whole abdomen was done, which showed no localized lymph nodes. In view of well-differentiated histology with no invasion of submucosa on biopsy and no localized lymph node enlargement patient was deemed as having low risk of lymph node metastasis (LNM). As per existing literature there is a 3 to 4% risk of LNM in T1a early gastric cancer (EGC).[1] Patient was planned for endoscopic submucosal dissection (ESD).

Patient underwent ESD under general anesthesia after elective endotracheal intubation in supine position. ESD was performed with a gastroscope (GIF-HQ190, Olympus, Tokyo, Japan) equipped with a transparent distal attachment (D-201-11804, Olympus, Tokyo, Japan). CO₂ insufflation with low-flow tubing was used throughout the procedure (Olympus CO₂ insufflator). Electrosurgical units enabled with a microprocessor was used for the whole procedure (ERBE, VIO 300D, Tübingen, Germany). Dual J knife (KD-655L, Olympus) was used for marking, incision, and submucosal dissection, and Coagrasper (FD-411UR, Olympus) was used for prophylactic coagulation and hemostasis. Initially marking of the lesion was done using NBI (soft coagulation, 60 W, effect 4). Submucosal injection using sclerotherapy needle (A 25 G sclerotherapy; V-JECTOR; Endo-Med, Uttar Pradesh, India) with saline and methylene blue was done at the proximal margin of the gastric lesion ([Video 1]). Following this, mucosal incision was done using dual J knife (Endocut I, duration 2, interval 2, effect 2) and dissection was started in submucosal plane from proximal to distal margin of the gastric lesion (forced coagulation, effect 2, 40 W; [Fig. 4]). Similarly, the dissection was done from distal margin to proximal margin in retroflexed view. Due to large area involved, decision to apply traction was taken. Traction was applied using dental floss clip (DFC) technique at the leading edge of dissected lesion to facilitate the submucosal dissection ([Fig. 5], [Video 1]). After application of traction, the lesion was dissected in submucosal plane, in toto. To complete the dissection, IT knife (IT knife 2, KD-611L, Olympus) was used. Visible vessels were cauterized using coagrasper (soft coagulation, 60 W, effect 4; [Fig. 6]). The entire lesion was removed in toto and final dissected specimen measured 6 × 3 × 1 cm. Patient developed no postprocedure complications. Histopathology of dissected specimen showed well-differentiated tubular adenocarcinoma, which invaded muscularis mucosae, and no invasion of submucosa were seen. Horizontal and vertical margins were free of tumor suggestive of curative R0 resection. No lymphovascular invasion was seen ([Fig. 7]).

Fig. 4 Dissection along submucosal plane between overlying mucosa and underlying submucosa.

Fig. 5 Application of traction using dental floss and hemoclip.

Fig. 6 Mucosal defect after completion of ESD. ESD, endoscopic submucosal dissection.

Fig. 7 Histopathology showing free inked margin (arrow head).

Practical Implications for Endoscopists

1. NBI is an important diagnostic modality for diagnosis of EGC. As per Yao et al the sensitivity, specificity, and accuracy for distinguishing cancerous from benign lesions were 92.9, 99.3, and 98.7%, respectively.[2] [3]

2. Application of retraction during ESD, help to reduce the dissection time, and ensure appropriate and complete dissection in submucosal plane. It improves visualization, reduces needs for repeated injections and less adverse events.[4]

3. As per previous study by Tamari et al, the indications for DFC during gastric ESD by less-experienced endoscopists include lesions located in the greater curvature of the upper or middle stomach and lesions > 20 mm located in the lesser curvature of the stomach. In 1,014 patients, when comparing lesions > 20 mm, the procedure time in the DFC (+) group was significantly shorter than that in the DFC (−) group (95 ± 46 vs. 75 ± 31, p < 0.01). The procedure time for lesions located in the greater curvature of the upper or middle stomach and lesions > 20 mm located in the lesser curvature side of the stomach in the DFC (+) group was significantly shorter than that in the DFC (−) group.[5]

4. The Japanese Gastric Cancer Association initially proposed that nonulcerated EGCs with differentiated-type histologic features, confined to the mucosa (T1a) and ≤20 mm, were ideal lesions and an absolute indication for ESD, given their low risk for LNM.[6]

5. In light of the excellent oncologic outcomes achieved with ESD, the criteria for endoscopic resection were subsequently expanded to include (1) nonulcerated differentiated EGCs of any size, (2) ulcerated differentiated EGCs < 30 mm, or (3) differentiated EGCs < 30 mm with superficial submucosal invasion (SM1; <500 μm below the muscularis mucosae).[6]

6. ESD allows en bloc resection of EGC and dysplastic lesions. The overall en bloc resection rate is 94.8% (128/135): 98.6% (72/73) for lesions fulfilling the absolute clinical criteria versus 90.3% (56/62) in the expanded clinical criteria group.[7]

 

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Conflict of Interest

None declared.

• References

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• 2 Yao K, Iwashita A, Tanabe H. et al. Novel zoom endoscopy technique for diagnosis of small flat gastric cancer: a prospective, blind study. Clin Gastroenterol Hepatol 2007; 5 (07) 869-878
• 3 Yao K, Anagnostopoulos GK, Ragunath K. Magnifying endoscopy for diagnosing and delineating early gastric cancer. Endoscopy 2009; 41 (05) 462-467
• 4 He Y, Fu K, Leung J. et al. Traction with dental floss and endoscopic clip improves trainee success in performing gastric endoscopic submucosal dissection (ESD): a live porcine study (with video). Surg Endosc 2016; 30 (07) 3138-3144
• 5 Tamari H, Oka S, Kotachi T. et al. Indications for dental floss clip traction during gastric endoscopic submucosal dissection by less-experienced endoscopists. J Gastric Cancer 2023; 23 (04) 512-522
• 6 Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer 2017; 20 (01) 1-19
• 7 Yang D, Kotzev AI, Draganov PV. Endoscopic submucosal dissection for early gastric cancer in the West: the absolute but not final word. Gastrointest Endosc 2019; 90 (03) 480-482

Publication History

Article published online:
07 July 2025