It is my pleasure to present our video case on self-dilation to prevent stenosis after circumferential esophageal ESD. These are our disclosures. Endoscopic submucosal dissection can be used to treat superficial neoplasia in the esophagus. However, circumferential ESD is associated with a high risk of esophageal stenosis, especially in cases with a significant longitudinal extent of the resection. And thus far, we unfortunately do not have an effective stenosis-preventing treatment for these cases. We would like to present the case of a 75-year-old woman who presented with dysphagia at an endoscopy without visible lesions elsewhere, but random biopsies to exclude esophaginic esophagitis showed high-grade dysplasia. And she was referred for endoscopic reassessment and treatment. We performed an endoscopy. Here you see a pullback in white light. And while pulling back, you see that here there is a change in the color of the mucosa and also the mucosal pattern is a bit more irregular. And while pulling back, you can see that this is quite extensive, more pronounced in some places, but the whole circumference is abnormal. And again, here you see the proximal start of the neoplastic area. Squamous neoplasia is often better seen with narrow band imaging. So here the pullback is repeated with NBI from distal to proximal. And again, you can see that here there is a brownish discoloration of the mucosa. It becomes a bit more irregular when you look at the mucosa. And these abnormalities are seen on the whole circumference of the esophagus, this area. The irregularities are a bit more pronounced. And while pulling back, you can clearly identify the proximal end of the neoplastic area here. We zoomed in on the IPCLs, but there was no suspicion on deep invasion, so we thought she might be a candidate for ESD. We concluded that there was a superficially spreading squamous cell cancer of 10 cm in circumference, without suspicion on deep invasion. A PET-CT scan was performed, which did not show lymph node or distant metastasis. And because we anticipated that there was a high risk of stenosis, we started teaching the patient self-dilation prior to the ESD. Within two weeks, she could advance a 14 mm bougie. This video shows the ESD procedure with the distal and proximal markings. We started with a circumferential anal incision. And here you see the mucosal incision at the oral site, starting with a submucosal injection, followed by a mucosal incision at the oral site over half of the circumference. The cut is made a bit deeper, and the muscular fibers here are cut to get good access to the submucosa. And the same is done on the opposite side, making two mucosal incisions with two tissue bridges for traction in between, followed by submucosal dissection in the tunnel, working from proximal to distal. And this is the first tunnel. And the second tunnel was created on the opposite side, followed by cutting of the submucosal bridges that were left in between the tunnels. And here you can see the final cut is made. And then we were left with a circumferential wound in the esophagus of 13 cm in length. The white spots you see are the injections of steroids in the submucosa to prevent stenosis. And histology showed a squamous cell cancer, invading into the muscular mucosa, well-to-moderately differentiated, no lymphovascular invasion, and the resection was radical. We started the patient on oral pregnancy alone. Over a course of four weeks, from 30 mg she was tapered to 5 mg. And two days after the procedure, she started self-dilation with a 10 mm Bougie, soon increased to 14 mm once a daily. And she could tolerate a normal diet with this approach. This is a video that we demonstrate with the permission of the patient. Here she is advancing a 14 mm Bougie. We put a piece of tape on the Bougie. It's white, you can see it near her left hand, to indicate how far the Bougie has to be introduced. She slowly advances the Bougie up until the marking. Then she leaves the Bougie in place for a couple of seconds. Before she removes it again. And eight weeks after the ESD, we perform the first endoscopy to inspect healing of the esophagus. Here you can see that the healing has nicely started at the proximal end of the wound. You will see the same at the distal end. This is still the area where the mucosa has not completely healed yet, but I can very easily pass with a diagnostic endoscope until I reach the stomach. No signs of stenosis. In conclusion, despite steroid injection and oral steroids in this 13 cm long circumferential ESD, this would have most likely have still required multiple endoscopic dilations. But due to the self-dilations, no endoscopic dilations were necessary in this case. So teaching self-dilations prior to ESD may allow selected patients undergoing extensive circumferential ESD to maintain an adequate diameter of the esophagus and thus preventing the need for multiple endoscopic dilations when self-dilations are initiated shortly after the procedure and maintained throughout the healing phase. We hope that if this video gets accepted, that we can show completely healed esophagus during DDW. Thank you for your attention.

self-dilation

stenosis prevention

circumferential esophageal ESD

esophageal stenosis

endoscopic dilation