Introduction

Gastric fundus is a technically difficult area for endoscopic submucosal dissection(ESD), even for experienced endoscopists, due to its anatomic features, thin wall, and abundant blood supply.

Aims & Methods

To evaluate the feasibility a novel ESD technique, the “topflight ESD” for the gastric fundus tumors resection.
Topflight ESD procedure: marking dots are applied 5 mm outside the lesion margins, using the tip of the ESD knife; a mucosal incision is made in the distal esophagus, ca 3 cm above gastroesophageal junction; a tunnel is created into the gastric wall; subepithelial injection is performed using an endoscopic needle and the water flush from the ESD knife; extensive dissection of the submucosal space in the fundus and proximal corpus is performed; the tumor is isolated from the surrounding tissues; the endoscope is removed from the submucosal tunnel and is inserted into the gastric lumen; mucosal incision is performed outside the dots rim using the ESD knife; en bloc resection is obtained, the specimen is retrieved; finally, the esophageal incision is closed using conventional through-the-scope clips.

Results

An 81-year-old male patient with history of a coronary bypass surgery, right lung lobectomy and MALT lymphoma, was referred to us. On a previous gastroscopy, a 6 cm flat lesion with no ulcer(Paris 0-IIa+b), was identified in the gastric fundus and greater curvature of the proximal body. Biopsies revealed a mixed type, moderately differentiated adenocarcinoma. After multidisciplinary team conference a decision for ESD resection was made. The ESD was performed according to the steps described above. After lesion characterization, marks were placed around the lesion. Then, an incision was made in the distal esophagus and a wide tunnel was created, dissecting the submucosa under the lesion. Then, a mucosal incision from the luminal side was made. During this stage there was a 3mm perforation, highlighting the risk of perforation when the cutting is done from the luminal side. That perforation was effectively closed with the use of through-the-scope clips. En bloc resection was achieved. The esophageal incision was closed. The obtained specimen was 75x50mm in size. Oral liquids were started on day 1 and the patient was discharged asymptomatic, on day 2. The pathological examination confirmed the presence of a mixed type, moderately differentiated adenocarcinoma SM2L0V0R0, pT1b. The patient was under clopidogrel and was admitted at day 10 due to bleeding from the ESD ulcer, treated endoscopically, and remains asymptomatic 2 months after.

Conclusion

We demonstrate a novel and minimally invasive endoscopic option that uses conventional ESD devices. To our best knowledge, this is the first report of gastric fundus epithelial tumor resection using this technique. The Topflight ESD might be considered in such cases in the future.

References

1. Hamada K, Horikawa Y, Koyanagi R, Shiwa Y, Techigawara K, Nishida S, Nakayama Y, Honda M. Usefulness of a multibending endoscope in gastric endoscopic submucosal dissection. VideoGIE. 2019 Oct 19;4(12):577-583.
2. Kitamura M, Miura Y, Shinozaki S, Yamamoto H. The pocket-creation method facilitates gastric endoscopic submucosal dissection and overcomes challenging situations. VideoGIE. 2021 May 28;6(9):390-394.
3. Baldaque-Silva F, Vilas-Boas F, Velosa M, Macedo G. Endoscopic submucosal dissection of gastric lesions using the "yo-yo technique". Endoscopy. 2013;45(3):218-21.
4. Baldaque-Silva F, Wang N, Rouvelas I, Omae M. Traction-assisted endoscopic submucosal dissection of a duodenal gastrointestinal stromal tumor. Endoscopy. 2022 Jun;54(6):E318-E319.
5. Omae M, Wang N, Löhr JM, Vujasinovic M, Baldaque-Silva F. Endoscopic submucosal dissection by using a new traction device. VideoGIE. 2021 Oct 27;6(12):543-545.
6.Baldaque-Silva F, Wang N, Omae M. Duodenal subepithelial neuroendocrine tumor removed by endoscopic submucosal dissection using internal traction with magnets. VideoGIE. 2022 Apr 23;7(7):259-261.