983 TUNNEL ASSISTED "FUNNEL” RESECTION: ESD OF LARGE CIRCUMFERENTIAL EGJ/CARDIA SIEWERT 2 LESION

Abstract

Listen

Translate article

A 74year old woman with alopecia, CAD on Plavix and Non-Hodgkin’s lymphoma s/p chemotherapy and radiation of the upper abdomen underwent endoscopy to evaluate dysphagia. It revealed a stenotic esophagus with diameter of 12-15 mm. Bougie dilation was performed. Three gastric lesions were seen: A large Paris IIa circumferential lesion extending from 1 cm proximal to the Z line to 4-5 cm distal to the Z line, a 4cm Paris IIb lesion at the proximal greater curvature lesion and a 2 cm cardia Paris Is lesion. Biopsy of all 3 lesions revealed adenoma. The patient was referred to us for ESD of the 3 lesions. There is scant literature on ESD of Siewert II EGJ lesions of gastric origin and virtually no literature on ESD for completely circumferential such lesions (Kim et al Surg Endo 2018). Circumferential en bloc resection of such lesions is challenging due to: 1. the narrow esophageal lumen and high EGJ vascularity, particularly in this patient with stenotic esophagus, post radiation fibrosis, and antiplatelet therapy. 2. the difficulty in achieving favorable scope position for ESD in the fundus and anterior cardia. Double bending scopes are helpful in this setting but not available in the US (Hamada VideoGIE 2019). We present a video that highlights techniques that can be used to achieve en bloc resection in such challenging lesions. The large circumferential lesion was removed in 424 minutes, specimen measured 7cm x 7cm. As shown on the video the “funnel” shaped specimen was affixed on cork in a way that orientation is preserved with the esophageal portion protruding through a hole. The second lesion was removed in 55 minutes, specimen measured 5.5 cm x 3.5 cm. The third lesion was removed in 44 minutes, specimen measured 2.5 cm x 2 cm. In all 3 cases, pathology revealed R0 resection of adenoma. The patient had delayed bleeding on POD#1 requiring endoscopic hemostasis. She also developed EGJ stricture requiring 7 endoscopic dilations over 3.5 months until resolution. The presented video includes the video of her follow-up endoscopy at 1 year showing well healed scars with no residual adenoma. We present an en bloc, R0 “funnel” resection of a challenging EGJ/cardia circumferential lesion in a patient with stenotic esophagus and post radiation fibrosis. A variety of advanced techniques were used to achieve successful en bloc resection including multiple tunnels, a 360 degree endoscope loop (previously described by us for EFTR in the fundus, VideoGIE 2019), omental plug for microperforation closure, and per-os traction using an external grasper. Even with expert skills and techniques the operator should expect long operative times for such resections but they are of major benefit to patients particularly for pre-cancerous lesions as they spare them extensive esophago-gastrectomy operations.