Simultaneous resection of Barrett's esophageal cancer and severe stenosis caused by reflux esophagitis

Abstract

A 60-year-old woman presented with dysphagia. Upper endoscopy revealed severe stenosis in Barrett’s esophagus with the internal diameter narrowed to 8 mm (Fig. 1). Contrast-enhanced CT ruled out metastasis. Tongueshaped brownish areas, where adenocarcinoma had been diagnosed, were approximately 5 to 7 mm in diameter. ESD extending 5 cm in the longitudinal direction was performed to resect the adenocarcinoma and the nearcircumferential stenosis site. Considering the severe fibrosis present, surgical entry was made 3 cm from the proximal end. At the stenosis site, EUS (20 MHz) revealed an intact submucosal layer around 0.5 mm of the circumference. In a retroflexed view from the stomach, we made an incision on the distal side of the stenosis. By advancing the endoscope into the submucosal layer by using the tunnel technique, we observed the most severe scarring (Fig. 2). Circumferential resection was completed (Fig. 3). Postoperative pathology revealed high-grade dysplasia and Barrett’s well-differentiated adenocarcinoma (Fig. 4). Kenacort was applied, and balloon dilation was performed on postoperative day (POD) 5 to prevent stenosis. The muscularis was exposed over the ulcer surface, and it was possible to permeate the gel into the remaining muscularis by expanding the balloon. Granulation tissue accompanied by extensive microvasculature was observed by magnified narrow-band imaging endoscopy on POD 12. By POD 15, granulation tissue was replaced by regenerating epithelium, with no post-ESD stricture formation apparent. On POD 60, Gastrografin contrast imaging confirmed smooth passage past the post-ESD lesion, and additional balloon dilation (to 18 mm) was performed. No stenosis or clinical symptoms were apparent at POD 90. n