Endoscopic Submucosal Dissection of Gastric Adenocarcinoma Involving the Pylorus Circumference

摘要

An 82-year-old Caucasian woman with multiple co-morbidities was undergoing endoscopic surveillance at our department for post-endoscopic curative resection of intramucosal adenocarcinoma of the gastric antrum. A follow-up upper endoscopy showed a superficial py-loric lesion (0-IIa+IIc, according to the Paris classifica-tion) located mainly in the bulbar segment and involv-ing about 2/3 of the pylorus circumference. A narrow band imaging (Olympus.) study revealed loss of both crypts and vascular pattern (Fig..1). The multidisci plinary assessment suggested an endoscopic resection by endoscopic submucosal dissection (ESD) technique. The procedure was then performed under general an-aesthesia using the ERBE ICC electrosurgical generator with Flush Knife (Fujifilm.) and IT knife nano (Olym-pus.). Carbon dioxide was used for insufflation. At first, small coagulation marks were made 2–5 mm around the lesion. Then, a sufficient lifting was obtained with sub-mucosal solution injection of Voluven., indigo carmine and epinephrine (1:250,000). ENDO CUT Mode was used for mucosal incision, forced coagulation for sub-mucosal dissection and soft coagulation for haemosta-sis. Due to lesion size and location, the retroflexion posi-tion was the main technical approach in the bulb (Fig..2), achieving complete and en block excision. In the subse-quent artificial ulcer, comprising the whole circumfer-ence of the pylorus, it was possible to identify the entire pylorus muscle ring (Fig..3). There were no complica-tions. Histology revealed a moderately differentiated in-tramucosal adenocarcinoma that was fully excised (R0) with no lymphovascular invasion or ulceration. To min-imize the risk of late pyloric stenosis, she empirically underwent oral corticosteroid therapy (30 mg of pred-nisolone per day), which was then tapered gradually (5 mg per week). The patient was discharged 48 h lat- er without complaints. On endoscopic revaluation, 3 months later, no residual lesion or pyloric stenosis was documented (Fig..4).