Sequential submucosal tunneling and endoscopic resection for symptomatic twin esophageal opposing lesions. There are no relevant disclosures for the others. Submucosal tunneling and endoscopic resection or STER is a safe and effective technique for subepithelial esophageal lesions. The procedure is associated with less morbidity and early recovery for patients. A 48-year-old gentleman presented with dysphagia to solids and liquids of one and a half years duration. E.G.D. Dunn at another hospital showed two subepithelial lesions in mid esophagus on opposite walls producing luminal obstruction. EUS guided FNB of the lesion was suggestive of spindle cell neoplasm. He was referred to us for further management. A CT scan of chest showed two lesions on either walls producing obstruction. An apartheid endoscopy showed a luminal compromise at 25 centimeter with two opposing subepithelial lesions causing luminal narrowing. The scope could be passed across with difficulty. An EUS Dunn at the same session showed two hypoepoic lesions on either side. These were homogenous hypoepoic in nature and there were no very esophageal lymph nodes. The lesions measured approximately 2 centimeters. After discussion it was decided to do stir of the proximal lesion as it was easier. This would be followed later with by stir of the distant lesion. As mucous incision was made 5 centimeter proximal to the first lesion, a submucosal tunnel was created and advanced towards the lesion. Dissection was made on the mucosal aspect to separate the lesion from the mucosa. This was done carefully not to injure the mucosa. The after dissection from the mucosal side the lesion was dissected from the muscle side and the once the dissection was complete the lesion was removed using a snare from the tunnel. After removing the tunnel was inspected following which the mucosal incision was closed with multiple clips. The lesion measured approximately 2 centimeter in size. Two months later the patient returned for the second procedure. This time the patient's symptoms were better however the endoscopy showed that there was still luminal narrowing. The lesion was situated at 26 centimeter and scarring was noted on the other wall. A mucosal incision was made 5 centimeter proximal to this lesion and after making an incision a submucosal tunnel was created. This was done by careful dissection of the submucosal fibers. The dissection was done by TT knife and the initial dissection was done on the mucosal aspect separating the lesion from the mucosal. There were few blood vessels seen during the dissection and this was calculated using the knife itself. After the mucosal side was dissected the muscular aspect was also dissected. Finally the lesion was separated from all its attachments. Once the lesion was dissected the lesion again was removed using a snare from the tunnel. The tunnel was then entered again to see for any bleeding points. Once it was clear that there was no further bleeding points the endoscope was slowly withdrawn from the tunnel carefully inspecting the tunnel. The mucosal incision then was closed with multiple clips so that the incision was closed fully. The lesion measured approximately 3 cm. The biopsy of the lesion showed spindle cell neoplasm. The IHC was suggestive of leiomyoma. Post procedure patient became asymptomatic. To conclude subepithelial lesions on opposing walls producing esophageal luminal compromise is a rare clinical scenario. Special submucosal tunneling and endoscopic resection is a safe and effective option to give relief and cure for such patients.

STER

subepithelial esophageal lesions

dysphagia

leiomyoma

endoscopic resection