LAUSR

Endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell carcinoma with esophageal varices (EVs) remains a challenging procedure with a high risk of bleeding. Recently, red dichromatic imaging (RDI) was developed as a new image-enhancing endoscopic technique. Under RDI, blood vessels in the deep submucosa can be easily and readily recognized [1]. RDI has been reported to improve the visibility of EVs [2] and to be effective for preventing bleeding in esophageal ESD, especially during submucosal injection [3, 4]. The patient was a 72-year-old man with alcoholic liver cirrhosis who had undergone previous endoscopic variceal ligation for EVs and balloon-occluded retrograde transvenous obliteration for gastric varices. Esophagogastroduodenoscopy (EGD) revealed a 5-mm 0-IIc lesion in the middle esophagus (▶Fig. 1 a, b), which was diagnosed as remaining in the epithelium or in the lamina propria mucosa at depth by magnified endoscopy with narrow-band imaging (▶Fig. 1 c). Since the lesion was located on esophageal varices, we first planned endoscopic injection sclerotherapy (EIS) for the varices followed by ESD. EGD performed 2 months after EIS revealed residual varices near the lesion (▶Fig. 1d, e). At the time of ESD, we observed the residual varices by means of RDI (▶Video 1, ▶Fig. 2 a). Subsequently, iodine staining was used to identify the lesion. After we made surrounding markings, the iodine was washed off with sodium thiosulfate (▶Fig. 2 b). We performed an injection and mucosal incision using RDI to avoid injuries in the blood vessels and EVs (▶Fig. 2 c). RDI also improved visibility of bleeding points during submucosal dissection. Finally, en bloc resection was achieved without any adverse events (▶Fig. 2d). Histopathology revealed squamous cell carcinoma restricted to the epithelium with negative margins and lymphovascular invasion. From our experience, it was evident that RDI improves visibility of the vasculature even after washing off iodine staining. ESD with RDI may be a safe and useful treatment for superficial esophageal squamous cell carcinoma with EVs. E-Videos