The set double tunnel technique. My name is Jürgen Hochberger. I have no conflict of interest to declare. A 53 year old patient was referred because of an obstructing tumor in the middle of the esophagus at the level of the aortic arch. You see here the yellowish tumor. The tumor was partially calcified. You see the barium swallow and then the CT scan. So we decided in discussion with our thoracic surgeons to do an attempt of endoscopic removal of that 3.5 centimeter tumor using the set technique. So you see here submucosal injection then incision and then dissection submucosally. We could finally free the tumor which was originating here from the circular muscularis propria layer. At the bottom it was attached. It was difficult to reach so we tried first with a snare but then finally completed the excision using the 1.5 millimeter flush knife. So here you see the tumor and we tried then to remove the tumor through the upper incision at the level of the cervical esophagus but the tumor was too bulky, too big to enter through that incision and to enter the esophageal lumen. So we were afraid to lacerate the cricopharyngeus. As the patient had an axial hernia we had the idea to continue the tunneling until the level of the distal esophagus and did a second longitudinal incision and freed the tumor from the submucosa and transferred it to the esophageal precardial lumen which was wide enough the way the tumor could be pushed forward into the stomach. Here you see the intact tumor and the fundus of the stomach and we finally cut it into several pieces which you see here and removed those pieces using a rosette. So histology showed a leiomyoma no malignancy. So you see here the tunnel directly at the end of the procedure here different clips we had to place because of the strong arterial vascularization at the level of the aorta and here the second incision for propagation of the tumor into the stomach. So we finally closed both incisions using standard clips and then also OTSC micro clips because of the long incisions. Here you see an adaptation by a grasper. So to prevent infection we placed additionally two polyurethane vacuum sponges at the level of the distal and proximal esophagus. So the sponges and so also in the further course the clips were removed without any problems and you see here the result three months later the patient didn't have any dysphagia. Here you see a slight web, a slight stricturing at the level of the distal esophagus but without any obstruction and without any dysphagia of the patient. Here the cornea where the tumor had been expulsed. See still that longitudinal incision and here a small sparium swallow through the esophagus. So we think this technique can be helpful and for these cases with the large tumors which are rather risky to be removed through the upper esophagus.

surgical technique

set double tunnel technique

esophagus tumor removal

calcified leiomyoma

distal esophagus incision