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VIDEO CASE REPORT
Endoscopic submucosal dissection of early gastric cancer in a
patient with situs inversus totalis
Yohei Koyama, MD,
1
Takashi Kawai, MD,
2
Taisuke Matsumoto, MD,
1
Masakatsu Fukuzawa, MD,
1
Takao Itoi, MD
1
Situs inversus totalis (SIT) is defined as the complete
mirror-image transposition of the thoracic and abdominal
viscera. It is a relatively rare congenital anomaly with an
incidence of approximately 1 per 4000 to 8000 persons.
1
Endoscopic submucosal dissection (ESD) is widely per-
formed as a treatment for early gastric cancer. This strategy
uses the effective countertraction produced by gravity,
which enables dissections to be performed quickly and
safely. However, in patients with SIT, this conventional
method is difficult to perform because of the inverted po-
sition of the stomach. Previously, Miyaoka et al
2
reported
the usefulness of an inverted overtube in patients with
SIT, but this overtube is not currently available because it
has been discontinued. Herein, we report a patient with
SIT and gastric cancer who underwent ESD.
A 74-year-old man with SIT presented to our hospital for
further evaluation of suspected gastric cancer identified on
screening EGD performed at another hospital. We per-
formed EGD using a magnifying endoscope (GIF-H290Z;
Olympus, Tokyo, Japan), and an 8-mm reddish, depressed
lesion was observed on the posterior wall of the antrum.
The demarcation line was identified clearly by indigo
carmine dye (Figs. 1A and B). Magnifying narrow-band im-
aging displayed an irregular microsurface and microvas-
cular patterns surrounded by the demarcation line. No
metastatic lesions were displayed on CT (Figs. 2A and B).
Early-stage gastric cancer was strongly suspected on the ba-
sis of the endoscopic findings. The entire procedure of ESD is
shown in Video 1d, available online at www.VideoGIE.org.
When the patient was positioned in the left decubitus
position, the lesion was hidden by gastric fluid because it
was located on the gravitational side. Furthermore, a clear
endoscopic view and good countertraction could not be
obtained in this position (Fig. 3). Therefore, we performed
ESD with the patient in the right lateral decubitus position,
and the operator stood on the opposite side (Fig. 4).
A mixture of glycerol and indigo carmine was used for
the submucosal injection. An electrosurgical generator
(VIO 300D; ERBE Elektromedizin GmbH, Tubingen, Ger-
many) was set at endocut I (effect 3, duration 3, interval
3) for mucosal incision and forced coagulation and at effect
3, 50 W for submucosal dissection. A circumferential
mucosal incision was performed with a 2.0-mm dual knife
(KD-650L; Olympus) and an insulated-tip knife (KD-611L;
Figure 1. A, B, An 8-mm, reddish, depressed lesion was observed on the posterior wall of the antrum. The demarcation line was identified clearly by
indigo carmine dye.
www.VideoGIE.org Volume -, No. -: 2020 VIDEOGIE 1
Olympus). First, the lesion’s lateral margins were marked
with a dual knife in forced coagulation mode (effect 3,
30 W). A mucosal incision was made as a pre-cut on the
distal side using a dual knife. Next, an insulated-tip knife
was inserted into the incision, and circumferential dissec-
tion was performed. Submucosal dissection was then per-
formed with an insulated-tip knife.
In the right lateral decubitus position, a clearer endo-
scopic view and good traction were obtained during
Figure 3. Endoscopy room setup in the left lateral decubitus position. Figure 4. Endoscopy room setup in the right lateral decubitus position.
The operator stood on the opposite side.
Figure 2. A, B, CT scan showed situs inversus totalis, and no metastasis lesion was seen.
2VIDEOGIE Volume -, No. -: 2020 www.VideoGIE.org
Video Case Report Koyama et al
ESD, and the tumor was successfully removed en bloc in
15 minutes. There were no procedure-associated adverse
events. Histopathologic examination of the resected spec-
imen led to the diagnosis of L, Gre, 25 25 mm, Type 0-
IIc, 8 8 mm, tub1, T1a (M), pUL0, Ly0, V0, pHM0, pVM0,
according to the Japanese classification of gastric carci-
noma (Figs. 5-7).
3
In conclusion, ESD in the right lateral decubitus posi-
tion for patients with SIT is a simple, effective method
that does not require other traction devices.
DISCLOSURE
All authors disclosed no financial relationships rele-
vant to this publication.
Abbreviations: ESD, endoscopic submucosal dissection; SIT, situs inver-
sus totalis.
REFERENCES
1. Iwamura T, Shibata N, Haraguchi Y, et al. Synchronous double cancer of
the stomach and rectum with situs inversus totalis and polysplenia syn-
drome. J Clin Gastroenterol 2001;33:148-53.
2. Miyaoka Y, Suemitsu, Fujiwara A, et al. Endoscopic submucosal dissec-
tion of early gastric cancer via inverted overtube in a patient with situs
inversus totalis: a case report. Endosc Int Open 2018;6:E625-9.
3. Japanese classification of gastric carcinoma：3rd English edition.
Gastric Cancer 2011;14:101-12.
Department of Gastroenterology and Hepatology, Tokyo Medical
University, Tokyo, Japan (1), Department of Gastroenterological
Endoscopy, Tokyo Medical University, Tokyo Japan (2).
Copyright ª2020 American Society for Gastrointestinal Endoscopy.
Published by Elsevier Inc. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.vgie.2020.04.021
Figure 5. The resected specimen. The histologic imaging in the yellow
box is shown in Figure 6.
Figure 6. A panoramic view. The red line indicates intramucosal lesion. The magnified imaging in the yellow box is shown in Figure 7.
Figure 7. In the mucosal layer, well-differentiated adenocarcinoma was
seen.
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Koyama et al Video Case Report
