Bonura Giuliano Francesco, Veiser Thomas, Dertmann Tobias, Hollerich Jorg, Manno Mauro, Despott Edward John, Yahagi Naohisa, Beyna Torsten
Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Carpi, Italy.
Department of Gastroenterology and Hepatology, Evangalisches Krankenhaus Düsseldorf, Düsseldorf, Germany.
VideoGIE. 2025 Mar 1;10(7):345-348. doi: 10.1016/j.vgie.2025.02.009. eCollection 2025 Jul.
We report the case of a 65-year-old man who was referred to our unit with a diagnosis of a large early Barrett's esophagus adenocarcinoma, extending for about 10 cm and involving two-thirds of the esophageal circumference. CT scan revealed a moderate esophageal variceal ectasia not visible at endoscopic evaluation; however, no sign of liver cirrhosis had been identified at abdominal ultrasound, elastography, and laboratory examinations. Therefore, after a preliminary discussion with the tumor board, we performed endoscopic submucosal dissection (ESD).
An ultraslim therapeutic endoscope (EG-840 TP Slim Treatment Gastroscope, Fujifilm, Tokyo, Japan) was used. This gastroscope has a 7.9-mm insertion tube endowed with a large 3.2-mm working channel and powered by an expanded angulation (210° up/160° down) that significantly improves maneuverability. Moreover, the latest-generation hybrid-knife (HYBRIDknife flex I-Type, Erbe, Tübingen, Germany) was used, further improving the cut and coagulate precision. The procedure was performed under amber-red-color imaging (Fujifilm) mode, specifically designed to enhance the visibility of deep vessels and submucosal space/muscle.
Following significant bleeding after first mucosal incision at the distal margin, the initial therapeutic plan of tunnel creation method was changed, and a complete circumferential incision was performed followed by a submucosal dissection assisted by the saline-immersion technique and double clip-line traction method. Importantly, during ESD a dense network of marked dilated esophageal varices (up to 7 mm in diameter) were encountered in the third space, significantly prolonging the procedural time. However, varices were all preventively identified and treated. Finally, the lesion was resected en bloc, and no adverse events occurred. The patient was discharged home 3 days later asymptomatic, and histopathological evaluation revealed a curative intramucosal adenocarcinoma (pT1a, m2, L0, V0, Bd1, R0, G1) resection. At 3-month endoscopic follow-up, no significant stricture or residual/recurrence neoplastic lesion were observed.
ESD of Barrett's esophagus adenocarcinoma located at esophageal varices may be considered a viable option even without previous variceal treatment.
我们报告一例65岁男性患者，因诊断为早期巨大巴雷特食管腺癌转诊至我科，肿瘤长度约10 cm，累及食管周长的三分之二。CT扫描显示有中度食管静脉曲张扩张，内镜检查未见；然而，腹部超声、弹性成像及实验室检查均未发现肝硬化迹象。因此，在与肿瘤委员会进行初步讨论后，我们实施了内镜黏膜下剥离术（ESD）。
使用超纤细治疗内镜（EG - 840 TP Slim治疗胃镜，富士胶片公司，东京，日本）。该胃镜插入管直径7.9 mm，工作通道大，直径3.2 mm，采用扩展角度（向上210°/向下160°）供电，显著提高了操作灵活性。此外，使用了最新一代混合刀（HYBRIDknife flex I型，爱尔博公司，图宾根，德国），进一步提高了切割和凝血精度。手术在琥珀红色成像（富士胶片）模式下进行，该模式专门设计用于增强深部血管及黏膜下间隙/肌肉的可视性。
在远端边缘首次黏膜切开后出现大量出血，遂改变最初的隧道创建法治疗方案，进行了完整的环形切开，随后采用盐水浸泡技术和双夹线牵引法辅助黏膜下剥离。重要的是，在ESD过程中，在第三间隙遇到密集的明显扩张的食管静脉曲张网络（直径达7 mm），显著延长了手术时间。然而所有静脉曲张均得到预防性识别和处理。最后，病变整块切除，未发生不良事件。患者3天后无症状出院，组织病理学评估显示为治愈性黏膜内腺癌（pT1a，m2，L0，V0，Bd1，R0，G1）切除。在3个月的内镜随访中，未观察到明显狭窄或残留/复发肿瘤病变。
即使未预先治疗静脉曲张，位于食管静脉曲张处的巴雷特食管腺癌ESD仍可被视为一种可行的选择。
