S4161 A Novel Suspension Bridge Technique for Endoscopic Submucosal Dissection of a Large Subepithelial Gastric Cardia Lesion

Introduction: Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique that allows for en bloc resection of subepithelial lesions located within the submucosal layer of the gastrointestinal (GI) tract. While ESD is widely used throughout the GI tract, its application in the gastric cardia presents unique challenges due to the cardia’s anatomic complexity and constant movement from respiration and cardia pulsations. We present a case of a large leiomyoma in the gastric cardia successfully removed via a modified ESD using a suspension bridge technique supported by natural traction. Case Description/Methods: A 47-year-old man with a history of hypertension and gastroesophageal reflux disease presented for evaluation of reflux symptoms and dysphagia. The patient underwent esophagogastroduodenoscopy (EGD)/endoscopic ultrasound (EUS), which showed a hypoechoic, well-defined lesion arising from the muscularis mucosa and measuring 35 mm × 15 mm. Multiple fine needle biopsies were performed. Pathology was consistent with leiomyoma of the stomach wall. Due to its primarily sub-mucosal, U-shaped, extraluminal position, accessing this lesion for dissection presents a unique challenge. To manage this, we employ a ‘suspension bridge’ technique, by creating and leaving behind suspension-like pedicles of submucosal bridges, to stabilize the lesion. After precise localization of the lesion, we inject into the submucosa to create a mucosal flap. This flap serves as the initial dissection point. As we extend the submucosal lift, we begin dissecting from the proximal end toward the gastroesophageal junction and the gastric cardia along the lesser curve. Given the twisted nature of the lesion, we deliberately halted the dissection, creating suspension-like pedicles of submucosal bridges to stabilize the lesion. This stepwise, segmented approach was repeated circumferentially, performing additional submucosal injections and dissections while preserving pedicles between each section. Once the circumferential dissection was complete, the remaining pedicles were carefully transected. This segmented approach prevents twisting and premature detachment, maintaining structural support and ensuring a complete en bloc resection with clear margins. Discussion: We presented a successful application of this novel approach, with a 6-month follow-up showing no recurrence or complications. This gravity-assisted traction technique, utilizing strategically preserved pedicles to stabilize the lesion, offers a promising solution for anatomically challenging lesions during ESD. Watch the video: https://tinyurl.com/25ACGS4161