Sequenzen:

Before starting any endoscopical procedure, in particular an endoscopic submucosal dissection, a proper and extensive evaluation of the lesion must be accomplished.
White light endoscopy, digital chromo endoscopy and magnification are useful technologies to assess the lesion extension, its limits and the mucosal and microvascular pattern. In this case, an Olympus 190 series upper GI scope provides narrow band imaging and near focus for a better evaluation.
A sub-cardial 15 mm IIA+IIC early gastric cancer is identified. The preoperative endoscopic biopsy informed a well differentiated adenocarcinoma.

After completing the submucosal space injection, the needle is exchanged for the ball tip shaped endoscopic knife, which has the ability to cut and also inject the previously described solution as required.
Our group supports a complete circumferential mucotomy before starting the submucosal dissection.

Submucosal dissection is carried out using the traction provided with the distal attachment. In this particular location, the dissection combines retroflex and forward view scope positions to achieve an en-bloc resection.
Repeated injections of the solution to the submucosal space allows a better visualization of the plane of the dissection, that should be carried out right above the muscular layer.
Small vessels are often encountered during the procedure. Most of them are adequately coagulated with the same knife. Larger ones may require hemostasis with coagulation forceps.