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DOI: 10.1055/a-0861-9953
Double ligation-assisted endoscopic submucosal resection for wider-margin resection of nonmuscularis propria subepithelial esophageal lesions
Corresponding author
Publikationsverlauf
Publikationsdatum:
13. März 2019 (online)
Esophageal subepithelial lesions (SELs) are common in endoscopy practice. Clinical management depends on multiple factors including tissue diagnosis and, thus, assessment of malignant potential [1]. With respect to endoscopic resectability and, if appropriate, choice of therapeutic modality, characterization of the layer of origin is critical. However, as conventional low-frequency endosopic ultrasound (EUS) may not reliably determine the origin of a muscularis mucosae lesion, for example, clear-cut differentiation of the muscularis propria and nonmuscularis propria localization is more relevant. From this perspective, apart from granular cell tumors, which have a high rate of tissue diagnosis on standard forceps biopsy, EUS puncture is often discussed, but is also often technically complicated in small-sized lesions. Therefore, a more straightforward approach in easy-to-resect nonmuscularis propria lesions may be more appropriate, given adequate patient counseling and preference. Here, a novel variant technique, which is an evolution of endoscopic submucosal resection with ligation (ESMR-L) and is designated “double ligation-assisted endoscopic submucosal resection” (ESMR-DL), for rapid wide-margin removal of small SELs is presented in three consecutive patients [2] [3].
[Table 1] and [Fig. 1] illustrate basic patient and SEL characteristics. In addition, [Fig. 2] and [Video 1] demonstrate the individual steps of the procedure. In brief, after EUS assessment of echogeneity, vascularity, and, particularly, muscularis propria layer integrity behind the respective lesion, a standard endoscopic variceal ligation (EVL) device is mounted, and the lesion is mobilized and suctioned into the cap. Notably, and unlike most descriptions of ESMR-L, this stage occurs without prior submucosal injection. Next, two bands are placed to increase luminal protuberance and, thus, basal resection margins, and the lesion is released. After removal of the EVL device, the lesion is visualized and snared below the bands using electrocautery. The en bloc specimen may then be retrieved by, for example, a Roth net, and sent for pathological assessment. The intervention is terminated by adequate analysis of the resection bed with or without clipping of the defect.
Age/sex |
Location[1] |
Size, mm |
Clip closure |
Complications |
Histology |
IHC analysis |
45/male |
Distal |
7 |
No |
None |
Leiomyoma |
Desmin + |
43/male |
Distal |
10 |
Yes |
None |
GCT[2] |
S-100 + |
69/female |
Middle |
9 |
Yes |
None |
Leiomyoma |
SMA + |
CD, cluster of differentiation; GCT, granular cell tumor; IHC, immunohistochemistry; SMA, smooth muscle antigen.
1 Respective third of esophagus
2 Tissue diagnosis available pre-resection
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Video 1 The steps of the double ligation-assisted endoscopic submucosal resection (ESMR-DL) procedure in Patient 3.
Qualität:
Endoscopy_UCTN_Code_TTT_1AO_2AG
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
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Competing interests
None
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References
- 1 Faulx AL, Kothari S. Standards of Practice Committee. et al. The role of endoscopy in subepithelial lesions of the GI tract. Gastrointest Endosc 2017; 85: 1117-1132
- 2 Lee DG, Kim GH, Park DY. et al. Endoscopic submucosal resection of esophageal subepithelial lesions using band ligation. Endoscopy 2011; 43: 822-825
- 3 Choi CW, Kang DH, Kim HW. et al. Endoscopic resection for small esophageal submucosa tumor: band ligation versus conventional endoscopic mucosal resection. Medicine (Baltimore) 2017; 96: e7574
Corresponding author
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References
- 1 Faulx AL, Kothari S. Standards of Practice Committee. et al. The role of endoscopy in subepithelial lesions of the GI tract. Gastrointest Endosc 2017; 85: 1117-1132
- 2 Lee DG, Kim GH, Park DY. et al. Endoscopic submucosal resection of esophageal subepithelial lesions using band ligation. Endoscopy 2011; 43: 822-825
- 3 Choi CW, Kang DH, Kim HW. et al. Endoscopic resection for small esophageal submucosa tumor: band ligation versus conventional endoscopic mucosal resection. Medicine (Baltimore) 2017; 96: e7574
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