A two centimeter submucosal lesion arising from muscularis mucosae is identified in the distal esophagus.
An osmotic agent, consisting in a Voluven based solution with indigo carmine, is injected in the submucosal space at the level in which the mucotomy is planned.
The needle is exchanged for an endoscopic knife and a longitudinal mucotomy of 15 to 20 mm long is created.
A submucosal tunnel is created from a point 5 cm proximal to the lesion. It is extended the distally until the tumor is identified, using a combination of blunt dissection and coagulation.
A pearl-white submucosal tumor is identified during the dissection. The lesion is dissected from the submucosal space and larger feeding vessels are coagulated with coagulation forceps and then sectioned. The distal attachment provides proper traction in order to assist the dissection.
Finally, after assuring adequate hemostasis, a gentamicin based solution is instilled into the tunnel.
The esophageal mucosa is closed with endoscopic clips starting from the distal end of the defect.