ASGE DDW Videos from Around the World | 2022-SUBMUCOSAL TUNNELING ENDOSCOPIC BIOPSY FOR MANAGEMENT OF UNKNOWN ESOPHAGEAL STENOSIS

Video Transcription

Here is a case. A 48-year-old man was admitted to our hospital, complaining of severe dysphagia for one month. The patient had been suffering from lung cancer for almost four years.  Since he was diagnosed, he received radical operation, chemotherapy, and radiotherapy. However, metastasis occurred one year later.  Then, charity therapy was conducted, after which the patient was evaluated as severe disease. Until one month ago, dysphagia occurred.  He underwent an esophageal dilation with spondylitis at a local hospital, with no significant improvement in the symptoms.  Given his medical history, the recurrence and metastasis of lung cancer and the side effects of treatment may be the causes of his esophageal stenosis.  PICT suggested that there might be inflammatory lesions in the mid-thoracic esophagus and mediastinal lymphadenitis.  We did the endoscopy ultrasound examination, revealing a thinning of the muscular layer in the esophageal stenosis, up to 5.5 mm. And no inline lymph nodes were found.  So far, no evidence pointed to cancer recurrency or metastasis.  After a full discussion, as the suture was similar to ecclesia, the ideal semicircular tunneling endoscopy biopsy entered.  With the advantage of concurrent muscle biopsy, the surgical plan was settled.  Ultrasound gastroscope exploration at our hospital showed the narrow segment of esophagus was 28-30 cm from the incisors with mucosa.  The procedure of our technique includes several steps as follows.  Step 1. Mucosal incision.  The side mucosal injection is performed, followed by a 2 cm longitudinal esophageal mucosal incision at the point tunnel entry at 3 cm above the narrow ring.  Step 2. Side mucosal channeling. A short side mucosal longitudinal channel is created between the mucosa and the muscularis propria until the narrow ring.  Step 3. Full thickness myotomy. Reaching the narrow esophagus, side mucosal adhesion may be severe. No side mucosal channeling could be continued.  The transparent cap should be removed temporarily in order to reduce mucosal injury and improve operative space.  The partial adhesion is separated and full thickness myotomy is performed through the narrow segment. Mucosal injury should be avoided.  Step 4. Muscle biopsy. Appropriate and sufficient pieces of muscle from the stretcher are obtained.  Step 5. Mucosal closure. After dealing with the wound with hot biopsy for steps, the channel entrance is closed with endoclips.

Video Summary

In this video, a 48-year-old man with a history of lung cancer is admitted to the hospital with severe dysphagia. Despite previous treatments, including surgery, chemotherapy, and radiation, the cancer has recurred and metastasized. The patient had undergone esophageal dilation at a local hospital but saw no improvement. Further examinations revealed inflammatory lesions in the mid-thoracic esophagus and mediastinal lymphadenitis. To determine the cause and plan treatment, an endoscopy ultrasound examination was conducted, which showed thinning of the muscular layer. After discussing the findings, a semicircular tunneling endoscopy biopsy was performed, including muscle biopsy. Steps included mucosal incision, side mucosal channeling, full thickness myotomy, muscle biopsy, and mucosal closure with endoclips. No evidence of cancer recurrency or metastasis was found. (Transcript does not provide any credits)

Keywords

lung cancer

severe dysphagia

esophageal dilation

endoscopy ultrasound examination

muscle biopsy