Tip-in underwater endoscopic mucosal resection for a flat gastric tumor

Abstract

Figures

During follow-up endoscopy in a patient with familial adenomatous polyposis, an 11-mm, whitish flat lesion (yellow arrowheads) was identified on the greater curvature of the lower gastric body. a White light imaging. b Narrow band imaging.

Schema and images of the technique used in this case. a First, marking was performed around the lesion using the tip of the snare. b Underwater conditions, 1 mL of saline was injected into the normal mucosa at the anal side of the lesion. c An incision was made in the elevated portion using the snare, and the snare tip was fixed (tip-in). d The snare was carefully closed, ensuring that all markings were included within it.

Post-resection ulcer after tip-in underwater endoscopic mucosal resection showing complete lesion removal.

Full text

Underwater endoscopic mucosal resection (UEMR) has been reported as a simple method for resecting small gastric lesions 1 2 . However, due to the thickness of the gastric wall, slippage of the snare tip occasionally occurs, especially with flat or depressed lesions. Tip-in UEMR is a new technique recently reported for duodenal and colorectal lesions 3 4 , which enables secure anchoring of the snare tip by making the mucosal incision at the distal side of the lesion. Herein, we report the first case of a gastric flat tumor treated with tip-in UEMR ( Video 1 ).

Tip-in underwater endoscopic mucosal resection for a flat gastric tumor.Video 1

A woman in her 30s with familial adenomatous polyposis underwent endoscopy, which revealed an 11-mm flat lesion on the greater curvature of the lower gastric body ( Fig. 1 ). The biopsy result was adenoma. As the lesion was a small adenoma, endoscopic submucosal dissection was deemed both time-consuming and overtreatment; therefore, snare resection was chosen as a treatment approach. Given the flat nature of the lesion, conventional UEMR was anticipated to cause snare tip slippage. We thus attempted a tip-in UEMR.

During follow-up endoscopy in a patient with familial adenomatous polyposis, an 11-mm, whitish flat lesion (yellow arrowheads) was identified on the greater curvature of the lower gastric body. a White light imaging. b Narrow band imaging.

After marking around the lesion with snare tip (SnareMaster Plus [15 mm]; Olympus, Tokyo, Japan) ( Fig. 2 a ), underwater condition was established, and 1 mL of saline was injected into the normal mucosa at the anal side of the lesion ( Fig. 2 b ). Mucosal incision was then performed using the tip of the snare ( Fig. 2 c ). After inserting and fixing the snare tip into the submucosa, the snare was gradually expanded to include the entire markings ( Fig. 2 d ) and subsequently closed for en bloc resection. The ulcer base was then cauterized ( Fig. 3 ) and clipped. No adverse events were observed. The time from water infusion to resection was 4 minutes. Histology revealed an adenoma with negative horizontal and vertical margins.

Schema and images of the technique used in this case. a First, marking was performed around the lesion using the tip of the snare. b Underwater conditions, 1 mL of saline was injected into the normal mucosa at the anal side of the lesion. c An incision was made in the elevated portion using the snare, and the snare tip was fixed (tip-in). d The snare was carefully closed, ensuring that all markings were included within it.

Post-resection ulcer after tip-in underwater endoscopic mucosal resection showing complete lesion removal.

Tip-in UEMR, a simple technique requiring no special skills, would be a useful option for resecting small gastric tumors.

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