Successful resection of a 16-cm half-circumferential lesion at the greater curvature of the stomach using the endoscopic submucosal large-tunnel method

Gastric endoscopic submucosal dissection (ESD) has become widespread since the development of endodevices and assistance methods. However, as the size of tumors being treated increases, one traction device alone is often not sufficient to apply countertraction. Lesions in the greater curvature are particularly challenging owing to their high risk of bleeding and perforation, and the tendency to accumulate fluid and blood. We report a case of ESD for a giant lesion using the submucosal large-tunnel method.

A 74-year-old man was diagnosed with a 16-cm large gastric carcinoma occupying half of the circumference at the mid-to-upper body of the greater curvature of the stomach ([Fig. 1 a]). Magnified endoscopic examination provided no clear evidence of a submucosal invasive carcinoma, therefore ESD was performed ([Video 1]). A large tunnel was created and extended with the endoscope in the retroflexed direction ([Fig. 1 b]). The end point of the tunnel was made in the fornix area using a multibending endoscope. After a peripheral incision had been made on the gravitational side, the entire circumferential incision was completed. By leaving a submucosal area at the oral side until the end of the procedure, the natural traction from the anal side continued to work throughout the ESD ([Fig. 1 c]). Careful consideration of the order of resection allowed the tumor to be resected using one tunnel, without the use of other assistance methods ([Fig. 1 d]). There were no adverse events. Histopathology indicated an intramucosal adenocarcinoma, 152 × 115 mm in size, with negative resection margins and no lymphovascular invasion ([Fig. 2]).

Fig. 1 Endoscopic views showing: a a 16-cm large gastric carcinoma occupying half of the circumference at the mid-to-upper body of the greater curvature of the stomach; b the submucosal large tunnel; c the appearance after entire circumferential incision – by leaving a submucosal area at the oral side, the natural traction (yellow arrow) from the anal side to the oral side could be seen; d the ulcer floor after completion of endoscopic submucosal dissection.

Video 1 A large gastric lesion was treated by the endoscopic submucosal large-tunnel method.

Fig. 2 Macroscopic appearance of the opened specimen, revealing an intramucosal carcinoma measuring 152 × 115 mm.

In terms of curative resection, there are few reports of ESD for giant lesions of > 15 cm. Various methods, such as traction, tunneling, or a combination method, have been devised but all are sometimes complicated [1] [2] [3]. By considering the order in which such lesions are resected, this large-tunnel method can be used to obtain reliable en bloc resection of giant lesions.

Endoscopy_UCTN_Code_CPL_1AH_2AZ

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Negishi R, Koizumi K, Ohata K. Endoscopic submucosal dissection for multiple gastric superficial adenocarcinomas identified in patient with familial adenomatous polyposis. Dig Endosc 2020; 32: e57-e58
• 2 Tachikawa J, Chiba H, Arimoto J. et al. Endoscopic submucosal tunnel dissection with ring-thread countertraction for a large gastric tumor with extensive severe fibrosis. VideoGIE 2020; 24: 11-13
• 3 Mori H, Rahman A, Kobara H. et al. Novel and effective countertraction using a ring-shaped thread for safer gastric and colorectal endoscopic submucosal dissection. Gastrointest Endosc 2016; 84: 735-736

Publication History

Article published online:
01 July 2022