Gel immersion endoscopic mucosal resection in early gastric cancer with bleeding: A case report

Abstract

Gel immersion endoscopy was developed by Yano for the treatment of bleeding. In this case, we performed gel immersion endoscopic mucosal resection to treat a bleeding gastric cancer. An 80-year-old man, with chronic renal failure and on aspirin treatment for ischemic heart disease, underwent endoscopic treatment for multiple early gastric cancers on the anterior and posterior walls of the pyloric ring. An endoscopic submucosal dissection was performed for gastric cancer on the anterior wall; however, the removal of the cancer on the posterior wall was complicated by tumor prolapse and bleeding. Gel formulation (VISCOCLEAR® Otsuka Pharmaceutical Factory, Inc., Tokushima, Japan) was used to immerse the bleeding tumor and subsequently facilitate the endoscopic mucosal resection. Various factors, such as the use of antithrombotic medication and underlying renal disease, can increase the risk of bleeding during endoscopic gastric cancer resection. If bleeding persists, the resection margin becomes obscured. Gel formulations, such as VISCOCLEAR®, can be applied to control bleeding and improve visibility. In this case, gel immersion was useful for endoscopic mucosal resection of the bleeding tumor. The use of gel immersion endoscopic resection should be considered for the treatment of early gastric cancer, however further cases should be evaluated.

Keywords: Bleeding; Chronic renal failure; Early gastric cancer; Endoscopic mucosal resection; Gel immersion.

Fig. 1

(a) Two lesions of early gastric cancer near the pyloric ring. (b) Bleeding from the tumor was observed gradually. (c) Obtaining a field of view for endoscopic submucosal dissection was difficult owing to bleeding from the tumor and prolapse into the duodenum. (d) Injection of the gel formulation provided a clear field of vision by preventing tumor prolapse into the duodenum.

Fig. 2

The stomach was filled with a gel formulation to obtain a clear view. (a) The tumor's boundaries were identified, and the snare was then strangulated. (b) After gel immersion resection. (c) Post-endoscopic resection specimen.

Fig. 3

(a) The loupe image is shown. (b) Localized tumor cells in the mucosa (Scale bar: 500 μm). (c) Localized tumor cells in the mucosa (Scale bar: 200 μm) (d) Localized tumor cells in the mucosa (Scale bar: 100 μm).