“Underwater” endoscopic submucosal dissection for superficial esophageal neoplasms

      Endoscopic submucosal dissection (ESD) is an effective and minimally invasive treatment for superficial esophageal neoplasms (SENs) without metastasis. However, ESD for SENs has a substantial risk of adverse events. The most serious adverse event is perforation due to deep burn. We hypothesized that water immersion might improve or minimize the thermal damage to the muscle layer by its heat-sink effect and visualization during ESD. We performed underwater ESD in 9 patients with SENs (Fig. 1; Video 1, available online at Bipolar electrocoagulation devices were considered preferable to monopolar devices in terms of reducing deep burn; therefore, we used a bipolar needle-knife with a water jet function (Jet B-knife; Zeon Medical, Tokyo, Japan). After a circumferential incision, as performed for conventional ESD, esophageal lumen was filled and submucosal injection with saline solution was done by water-jet function through the Jet B-knife; soon thereafter, submucosal dissection could be performed seamlessly. The use of an overtube or endotracheal intubation can reduce the risk of aspiration. Even where the identification of an appropriate dissection layer was difficult because of fibrosis, water immersion yielded a more precise procedure. There were no adverse events. Underwater ESD for SENs was found to be feasible.
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      Figure 1“Underwater” endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell neoplasms. Arrowheads reveal the appropriate dissection layer, just above the muscularis propria. We finally achieved complete endoscopic and histologic resection without perforation. A, Flat lesion 50 mm in diameter in the midesophagus. B, Submucosal dissection could be performed seamlessly soon after submucosal injection by water-jet function with a Jet B-knife. C, Ulcer bed after underwater ESD was performed without perforation. D, Flat lesion, 25 mm in diameter, adjacent to post-EMR scar in the midesophagus. E, Even where it was hard to identify an appropriate dissection plane because of fibrosis, the underwater technique helped to identify the dissection layer and yielded a more precise procedure. F, Ulcer bed after underwater ESD was performed without perforation.
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