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CC BY 4.0 · Endoscopy 2024; 56(S 01): E258-E259
DOI: 10.1055/a-2275-0894
E-Videos

Successful underwater endoscopic submucosal dissection with gel immersion for early gastric cancer in an upside-down stomach

Takahiro Muramatsu 
1   Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan (Ringgold ID: RIN183786)
,
Tomoaki Tashima 
1   Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan (Ringgold ID: RIN183786)
,
Tsubasa Ishikawa 
1   Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan (Ringgold ID: RIN183786)
,
Tomonori Kawasaki
2   Pathology, Saitama Medical University International Medical Center, Hidaka, Japan (Ringgold ID: RIN183786)
,
Yumi Mashimo
1   Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan (Ringgold ID: RIN183786)
,
Takao Itoi
3   Gastroenterology and Hepatology, Tokyo Medical University Hospital, Shinjuku-ku, Japan (Ringgold ID: RIN38548)
,
Shomei Ryozawa
1   Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan (Ringgold ID: RIN183786)
› Author AffiliationsSupported by: Japan Society for the Promotion of Science JSPS KAKENHI/grant number 23K15052
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An upside-down stomach (UDS) is a relatively rare type of esophageal hiatal hernia; almost the entire stomach prolapses into the posterior mediastinum in affected patients [1].

Surgical procedures for gastric cancer arising from a UDS have been reported [2]; however, no reports on endoscopic submucosal dissection (ESD) for early gastric cancer arising in a UDS are available. In patients with a UDS, endoscope maneuverability is poor because their stomachs are inverted. Recently, water or gel immersion has been reported to be useful for improving the field of view and scope maneuverability [3] [4] [5]. Herein, we describe underwater ESD with gel immersion performed successfully for early gastric cancer arising from a UDS ([Video 1]).


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Successful underwater endoscopic submucosal dissection with gel immersion for early gastric cancer arising in an upside-down stomach.Video 1

An 85-year-old woman with a UDS ([Fig. 1] a,b) presented with early gastric cancer (lesion size 10 mm, type 0-IIc) located on the lesser curvature of the upper body ([Fig. 2] a,b). Approaching the lesion was difficult due to the UDS; thus, gas was removed from the lumen and replaced with water and gel (Viscoclear; Otsuka Pharmaceutical, Tokushima, Japan) to establish an underwater condition. The water–gel mixture maintained a lower intraluminal pressure and allowed us to approach the lesion, even from its distal side, under a clearer view ([Fig. 3] a–h).

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Fig. 1 Computed tomography (CT) image and schema of the upside-down stomach (UDS). a CT image shows that the entire stomach has prolapsed into the thoracic cavity through the hiatal hernia b Schema of the UDS.
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Fig. 2 Endoscopic image a White light image. Upper gastrointestinal endoscopy shows a depressed lesion (0-IIc) located on the lesser curvature of the upper body (diameter 10 mm). b Indigo carmine dye image.
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Fig. 3 Schema of underwater endoscopic submucosal dissection (ESD) with gel immersion in an upside-down stomach (UDS). a View under gas. b Attempts to approach the lesion. c The endoscope is pulled back. d Pushing the endoscope fails to achieve access to the lesion. e Markings around the lesion. f Removal of the gas from the lumen. g Underwater view. h View under combined water and gel (Viscoclear; Otsuka Pharmaceutical, Tokushima, Japan) immersion; the conditions established allow access to the lesion. i Local injection. j Initial mucosal incision is made on the distal edge of the lesion. k The mucosal incision is widened to the right and left. l A whole circumferential incision is made. m Submucosal dissection is performed. n En bloc resection is achieved.

A mucosal incision was made on the distal side to mark the incision limit. This was followed by a proximal mucosal incision and a complete circumferential incision. Finally, submucosal dissection was continued, and a complete en bloc resection was performed ([Fig. 3] i–n). Additional gel was injected as needed to obtain a clear view of the submucosal layer.

In conclusion, low-pressure endoscopy with water and gel immersion may help endoscopists overcome poor endoscope operability in procedures involving a UDS. This approach may further reduce the patient’s suffering, stabilize their condition, and enable safe resection of UDS lesions.

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Publication History

Article published online:
14 March 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

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