Esophagus - ESD for Circumferential Barrett's Esophageal cancer
Comments: This is a typical case of Barrett's esophagus.
Endoscopy reveals irregular mucosa and I diagnosed this lesion as an adenocarcinoma from such findings. However, the lateral extension was obscure. NBI endoscopy revealed irregular mucosal pattern, but the lateral extension was still unclear.
On the other hand, Magnified endoscopy with NBI system reveals irregular micro vessels very well and Lateral extension of this cancer could be diagnosed from such findings.
At the first I place marks around the lesion. And I injected 10% glycerol into the submucosal layer to separate the mucosa from proper muscular layer. After that, I started circumferential mucosal incision of anal part. I inserted the hook knife into submucosal layer and hooked the mucosal to gastric lumen. This is a very important point to prevent perforation. Usually, I used dry cut mode for mucosal incision. The direction of hook knife could be controlled by handle rotation.
After that, I started circumferential mucosal incision of oral side. Then, I dissected submucosal layer from oral to anal. Now I finished circumferential mucosal incision of oral side.
You have to observe submucosal layer very well and find proper mucosal layer and muscularis mucosa. And this lucent area is submucosal layer. I controlled the direction of hook knife parallel with the proper muscular layer and inserted the knife into submucosal layer. Then, I hook the submucosal fivers with the arm part of hook knife.
This is an endoscopic view during submucosal dissection. Submucosal tunnel has been making. I continued submucosal dissection and the amount of fibers became severe in the lower esophagus. Therefore, ESD for Barrett's esophageal cancer is more difficult than that of Squamous cell carcinoma.
You have to be careful to avoid injuring large vessels during submucosal dissection.
And when you find a large vessel 1mm or more in size, Precoagulation using haemostatic forceps is useful. I grasped this large vessel with coagulaspa and coagulate it with soft coagulation current. After that, I could cut this large vessel without bleeding. I always use spray coagulation mode in such situation.
Now, I finished ESD for the patients, It took three hours, under general anesthesia. And the length of ESD ulcer was 11 cm. There were no perforation and bleeding.
This is the resected specimen. A precise pathological examination could be performed by such a beautiful en bloc resected specimen. The invasion depth was mucosal layer and lateral and vertical margin was negative. The size of cancer was 94mm.
Severe stricture must be happened after circumferential ESD. Therefore, I started balloon dilatation three days after ESD, twice a week. You have to take care to dilate gradually to prevent perforation.
18 time balloon dilatation has been performed and the huge ESD ulcer was covered by non neoplastic squamous cell epithelium without stricture.
Two hundred and twenty six patients were treated by ESD and the median tumor size was 32 mm and Median specimen size was 38mm.
Complete resection rate was 94%,
We didn't experienced severe complications. 2 cases of derailed perforation were experienced, but could be treated with intravenous antibiotics and fast.
The local recurrence rate was only 0.4% and the case could be treated by re-ESD.
The advantage of ESD is En bloc resection and precise pathological examination could be performed. And Local recurrence was rare.
The disadvantage of EDS is longer procedure time and experienced skill. Therefore, training system should be established.
In conclusion, EDS is a safe and useful procedure for the treatment of superficial esophageal cancer.
| Contributed by: |
Tsuneo Oyama, MD
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Citation: Oyama, T. (May 19 2008). Esophagus - ESD for Circumferential Barrett's Esophageal cancer. The DAVE Project. Retrieved Sep, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=765 Times viewed since Feb 2006: 3613 |
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