Underwater endoscopic mucosal resection for a protruding lesion in the esophagus

A 70-year-old man with a history of ischemic cardiopathy, taking clopidogrel as his usual treatment, was referred because of cholangitis. Computed tomography and magnetic resonance imaging scans revealed a dilated bile duct without any obvious obstruction. Gastroscopy and endoscopic ultrasound were performed in search of an ampulloma, and unexpectedly identified a sessile tumor 2 cm above the gastroesophageal junction ([Fig. 1]). Gastroscopy performed with a high definition endoscope and magnification (EG-760Z; Fujifilm, Tokyo, Japan) confirmed a 0-Ip esophageal lesion with a suspicious irregular mucosal and vascular pattern ([Fig. 2]).

Fig. 1 Sessile lesion in the esophagus.

Fig. 2 Suspicious vascular and mucosal pattern.

In the absence of endoscopic features suggesting deep submucosal invasion, endoscopic resection was chosen. Owing to the sessile shape of the lesion, an underwater endoscopic mucosal resection (UEMR) was performed. We used a water pump to fill the entire esophageal lumen with saline ([Video 1]). A 15-mm diathermic snare was deployed to encircle the tumor, and was then closed on the polyp ([Fig. 3]). Safe margins were confirmed endoscopically before resecting the lesion using an Endocut current. After the resection, minor bleeding was successfully treated with the tip of the snare in soft coagulation mode, and the wound was closed with standard clips.

Video 1 Underwater endoscopic mucosal resection for a sessile esophageal lesion.

Fig. 3 Closing the snare on the lesion.

The resected specimen was 1.5 × 0.8 × 0.6 cm in size. Histological examination revealed a well-differentiated intramucosal adenocarcinoma, with margins free of dysplasia and cancer.

Previous studies have reported colorectal [1] [2] [3] and gastric [4] UEMR as an alternative to classic EMR. To the best of our knowledge, this is the first UEMR reported for an esophageal lesion. UEMR can be used for small sessile or pedunculated lesions in the esophagus, and is safe, fast, and efficient.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Kamal F, Khan MA, Lee-Smith W. et al. Underwater vs conventional endoscopic mucosal resection in the management of colorectal polyps: a systematic review and meta-analysis. Endosc Int Open 2020; 8: E1264-E1272
• 2 Li P, Ma B, Gong S. et al. Underwater endoscopic mucosal resection for colorectal lesions: a meta-analysis. Surg Endosc 2021; 35: 3003-3013
• 3 Binmoeller KF, Weilert F, Shah J. et al. “Underwater” EMR without submucosal injection for large sessile colorectal polyps (with video). Gastrointest Endosc 2012; 75: 1086-1091
• 4 Maida M, Sferrazza S, Murino A. et al. Effectiveness and safety of underwater techniques in gastrointestinal endoscopy: a comprehensive review of the literature. Surg Endosc 2021; 35: 37-51

Publication History

Article published online:
24 June 2022