Circumferential Endoscopic Submucosal Dissection of long-segment Barrett's Esophagus with Multifocal High-Grade Dysplasia

Abstract

In a case of long-segment Barrett's esophagus with multifocal high-grade dysplasia with multiple comorbidities, circumferential endoscopic submucosal dissection was performed. Following the procedure, the esophageal stricture was also managed.

Keywords

Barrett's esophagus - endoscopic submucosal dissection - esophageal stricture - high-grade dysplasia

Case Report

A 79-year-old male patient presented with persistent retrosternal burning and high-volume reflux for the last 5 years. His reflux symptoms had become refractory to proton pump inhibitors and prokinetic agents since the past 2 years. He had significant comorbidities as he had panhypopituitarism and a history of stroke with left carotid artery stenosis. He underwent an esophagogastroduodenoscopy (EGD) at our center that revealed a long-segment circumferential Barrett's esophagus with irregular surface and vascular pattern (C8M8, Paris 0-IIb) ([Fig. 1]). Multiple biopsies were taken as per the Seattle protocol that revealed Barrett's esophagus with multifocal high-grade dysplasia.

Fig. 1 Retroflexion view showing long-segment Barrett's esophagus.

A multidisciplinary discussion about treatment options was done, and oesophagectomy was considered as high risk because of associated comorbidities. He underwent a CECT chest and abdomen, which revealed no significant mediastinal or abdominal lymphadenopathy. We decided to do a circumferential endoscopic submucosal dissection (ESD) of Barrett's segment in view of multiple comorbidities. The pocket-creation ESD method was employed.[1] We used a hybrid knife, VIO 200D electrogenerator (ERBE) with a forward-viewing endoscope (GIF-HQ190; Olympus, Tokyo, Japan) and a carbon dioxide (CO₂) insufflator (UCR; Olympus, Tokyo, Japan). We created an anterior and a posterior tunnel by submucosal dissection and these were subsequently joined, hence an en-bloc resection could be achieved. The procedure took 150 minutes to complete, and the 8-centimeter long circumferential specimen was sent for histopathological examination ([Fig. 2]-[4], [Video 1]). Histopathological examination confirmed an R0 resection of a long-segment Barrett's esophagus with multifocal high-grade dysplasia and foci of T1a adenocarcinoma. The patient underwent a gastrografin swallow study on a subsequent day and could be started on a liquid diet on that day.

Fig. 2 Pocket-creation ESD using a hybrid knife.

Fig. 3 Proximal margin of the cut surface.

Fig. 4 Circumferential resected specimen with scale to measure (8 cm).

Video 1 Final esoesd.

The rate of stricture occurrence after near-circumference or whole-circumference ESD has been reported to be between 60 and 100%.[2] The patient underwent an OGD after 1 month that revealed a concentric short-segment stricture along the proximal margin of dissection ([Fig. 5]). He underwent balloon dilatation of the stricture with an injection of triamcinolone acetonide (40 mg/mL diluted as 1:1 with saline solution) using a 23-gauge, 5-mm long sclerotherapy needle in aliquots of 0.5 mL in each quadrant ([Fig. 6]).[3] The patient was already on oral corticosteroids for panhypopituitarism, and fortunately did not have a stricture recurrence. He underwent another EGD after 3 months that revealed reappearance of healthy squamous mucosa throughout the resected surface ([Fig 7]).

Fig. 5 Post ESD esophageal stricture formation at 1 month.

Fig. 6 Esophageal stricture CRE dilatation.

Fig. 7 Follow-up after 3 months.

Conflict of Interest

None declared.

• References

• 1 Harada H, Murakami D, Suehiro S. et al. Water-pocket endoscopic submucosal dissection for superficial gastric neoplasms (with video). Gastrointest Endosc 2018; 88 (02) 253-260
• 2 Martínek J, Juhas S, Dolezel R. et al. Prevention of esophageal strictures after circumferential endoscopic submucosal dissection. Minerva Chir 2018; 73 (04) 394-409
• 3 Kochhar R, Makharia GK. Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures. Gastrointest Endosc 2002; 56 (06) 829-834

Publication History

Article published online:
15 December 2022