Introduction: Recent trends have shown a rising incidence of gastric cancer in individuals diagnosed with familial adenomatous polyposis (FAP). The complexities of managing these cases are heightened due to the propensity for advanced lesions to originate from the backdrop of polyps, which can also occur in anatomically challenging locations, rendering endoscopic resection a technical hurdle. In this case report we describe a case of a 50-year-old female patient with a history of FAP who underwent successful endoscopic submucosal dissection (ESD) of a large sessile polyp in the gastric fundus.
Case Description/Methods: A 50-year-old female patient with FAP who was diagnosed with a large 6cm sessile polyp in the gastric fundus and proximal gastric body on surveillance esophagogastroduodenoscopy (EGD) was referred to our institution for gastrectomy. Our surgeons asked for our second opinion. The challenging location of the lesion in the gastric fundus required meticulous precision in resection (fig A). The submucosal layer was initially injected with ORISE gel, creating a distinct plane for the subsequent incision. A comprehensive circumferential incision was then carefully executed around the lesion using a synergistic combination of ORISE knife and Insulated tip (IT) knife. To ensure optimal visibility of the submucosal layer, a 20mm traction wire was effectively utilized, enabling superior exposure. Dissection of the submucosa was carried out using a strategic combination of IT knife and ORISE knife, ensuring careful preservation of the surrounding tissues (fig B). During the dissection, we encounter bleeding in a gravity dependent area. To improve visibility, we changed the patients position to shift the center of gravity and prevent pooling of the blood. This allowed us to pinpoint the origin of the bleeding and stop it with coagulation graspers. The pathology revealed en-bloc R0 resection of mixed foveolar and fundic gland-type gastric adenoma with low-grade dysplasia gastric adenoma (fig C). This was within curative endoscopic resection criteria. At 3 months, the patient remains cancer free with no evidence of recurrence on endoscopic surveillance (fig D).
Discussion: ESD in the fundus of the stomach can be technically challenging due to the angulation, vascularity of the region and risk of perforation. However, it can be safely performed with good planning and traction.
