Traction-assisted endoscopic submucosal dissection with submucosal tunneling for Barrett’s esophagus nodularity

Barrett’s esophagus (BE) is a premalignant condition with significant risk for esophageal adenocarcinoma. Endoscopic therapy is recommended after mucosal irregularities are found during surveillance [1]. Endoscopic mucosal resection (EMR) is sufficient to determine the depth of invasion. However, endoscopic submucosal dissection (ESD) facilitates en bloc resection and provides better assessment of the lateral margin of the lesion. ESD is technically more difficult than EMR but can be performed when bulky lesions are encountered or when submucosal invasion is suspected [1] [2].

A 59-year-old man with BE was found with associated nodularity that measured 2.3 × 2.4 mm at 38 cm from the dental arch ([Fig. 1], [Video 1]).

Fig. 1 Barrett’s esophagus nodularity at 38 cm from the dental arch.

Video 1 Traction-assisted endoscopic submucosal dissection with submucosal tunneling for Barrett’s esophagus nodularity.

The borders of the lesion were marked in a circumferential pattern using the tip of the HybridKnife T-type (Erbe, Tübingen, Germany). The submucosal space was accessed with a horizontal incision about 3–4 cm proximal to the lesion. A submucosal tunnel was created and then extended to the submucosal space below the lesion. The distal part of the lesion was dissected using repeated submucosal injection with saline mixed with methylene blue, followed by short bursts of dissection. The lateral borders of the lesion were dissected from the muscularis propria using mostly the ITknife2 (Olympus, Center Valley, USA). Fibrosis was encountered during dissection and internal traction was applied to facilitate the resection of the lesion. An elastic traction device (Micro-Tech, Nanjing, China) was attached to one of the borders of the lesion ([Fig. 2]). A second clip (SureClip; Micro-Tech) was then used to pull the plastic ring distal to the lesion to provide sufficient traction, and the submucosal dissection was continued until the lesion was completely resected en bloc. The resection margins were negative, and the final pathology showed no dysplasia.

Fig. 2 Elastic traction device was attached to the lesion to be pulled distally using another clip.

This case illustrates perfectly how internal traction facilitates ESD when fibrosis makes dissection difficult.

Endoscopy_UCTN_Code_TTT_1AO_2AC

• References

• 1 Weusten B, Bisschops R, Coron E. et al. Endoscopic management of Barrett’s esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2017; 49: 191-198
• 2 Shaheen NJ, Falk GW, Lyer PG. et al. ACG Clinical Guideline: Diagnosis and management of Barrett’s esophagus. Am J Gastroenterol 2016; 111: 30-50