Endoscopic submucosal dissection of intramucosal adenocarcinoma on Barrett's esophagus

A 63-year-old man was investigated because of long-standing pathological gastroesophageal reflux. Diagnostic endoscopy showed long-segment Barrett’s esophagus associated with a flat lesion compatible with a granular laterally spreading tumor (LST-G), and endoscopic submucosal dissection was decided upon [1].

A Fujinon EG-590-ZW diagnostic endoscope was used for the procedure. A Fujinon transparent conical cup and Fujifilm 1.5-mm FlushKnife BT were used as the dissecting instruments.

The endoscope was advanced to the distal esophagus, where long-segment Barrett’s esophagus (6 cm in length) was confirmed. In addition, a homogeneous flat lesion compatible with a LST-G of 4 cm maximum diameter was shown ([Fig. 1]).

Fig. 1 Granular laterally spreading tumor in the esophagus of a 63-year-old man.

Flexible spectral imaging color enhancement (FICE) and magnification were used for exhaustive assessment of the surface and margins of the lesion, which presented a granular flat segment on its edges.

The edges of the lesion were marked with a safety margin of 5 mm ([Fig. 2]). The lesion was then raised by submucosal injection with a solution made up of 500 mL Voluven, 2.5 mL methylene blue, and 1 mg epinephrine. A complete perimeter mucotomy, external to the marking, was performed ([Fig. 3]). Careful hemostasis was carried out, followed by endoscopic dissection of the submucosal layer adjacent to the muscularis propria ([Fig. 4]) [2]. The entire submucosal layer of the lesion in the dissected specimen was included. The surgical bed was undamaged, with no signs of perforation and correct hemostasis ([Fig. 5]; [Video 1]).

Fig. 2 The edges of the lesion were marked with a safety margin of 5 mm.

Fig. 3 Perimeter mucotomy was performed external to the marking.

Fig. 4 The submucosal layer adjacent to the muscularis propria was dissected.

Fig. 5 The surgical bed was undamaged.

Video 1 Endoscopic submucosal dissection of the distal esophagus.

At 6-month post-procedure follow-up the wound had healed. Re-epithelialization with squamous mucosa without evidence of esophageal stenosis was demonstrated. On this occasion, the remaining Barrett’s esophagus was ablated using radiofrequency.

The pathological report was of well-differentiated, intramucosal adenocarcinoma without compromise of lateral or deep margins.

Carrying out ESD for incipient neoplastic lesions in Barrett’s esophagus is feasible and safe [3] and achieves good oncological results. It should be followed by radiofrequency ablation of the remaining Barrett’s esophagus [4] [5].

Endoscopy_UCTN_Code_TTT_1AO_2AG

• References

• 1 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854
• 2 Oyama T. Esophageal ESD technique and prevention of complications. Gastrointest Endosc Clin North Am 2014; 24: 201-212
• 3 Park HC, Kim DH, Gong EJ. et al. Ten-year experience of esophageal endoscopic submucosal dissection of superficial esophageal neoplasms in a single center. Korean J Intern Med 2016; 31: 1064-1072
• 4 Barret M, Cao DT, Beuvon F. et al. Endoscopic submucosal dissection for early Barrett’s neoplasia. United European Gastroenterol J 2016; 4: 207-215
• 5 Frei N, Frei R, Semadeni GM. et al. Endoscopic treatment of early Barrett’s adenocarcinoma and dysplasia: focus on submucosal cancer. Digestion 2019; 99: 293-300