Endoscopic Ultrasonography of the Lower Esophageal Sphincter in Reflux Esophagitis and Achalasia

Abstract: The endoscopic ultrasonography findings at the lower esophageal sphincter (LES) were compared in patients with reflux esophagitis and esophageal achalasia to clarify the differences in wall structure between these diseases. In reflux esophagitis, the esophageal wall was hypertrophied at the LES and featured both irregularity and interruption of the submucosa, muscularis propria, and adventitia. In achalasia, there was generalized hypertrophy of the esophageal wall at the LES including the mucosa, submucosa, muscularis propria and adventitia but for each layer the normal 5-layer structure was visualized well. Thus achalasia and reflux esophagitis both featured hypertrophy at the LES, but the detailed findings were quite different. This difference was thought to arise from the presence of inflammation in reflux esophagitis and no inflammation in achalasia.     

Esophageal carcinoid tumor treated by endoscopic resection

The present report describes a rare case of esophageal carcinoid tumor that was treated by endoscopic resection. A 43‐year‐old woman underwent esophagogastroduodenoscopy at her family clinic for screening of the upper digestive tract and a small lesion resembling a submucosal tumor was detected in the lower esophagus. A biopsy sample from the lesion was diagnosed as esophageal carcinoid tumor and the patient visited our hospital for detailed examination. The tumor was approximately 3 mm in diameter and its surface appeared to be covered with normal squamous epithelium. The tumor had a shiny reddish surface without ulceration or erosion. Magnifying endoscopy with narrow‐band imaging showed structures resembling reticular vessels under the epithelium. Endoscopic ultrasonography depicted the tumor as a low‐echoic mass within the lamina propria. Computed tomography did not detect the tumor and no metastatic lesions were evident in other organs. With the patient's informed consent, the tumor was resected using endoscopic submucosal dissection, with a sufficient free margin in both the vertical and horizontal directions. Magnifying endoscopic examination showed the resected tumor to have abundant reticular vessels. Finally, the tumor was diagnosed immunopathologically as an esophageal carcinoid tumor (neuroendocrine cell tumor, grade 1), without lymphatic or vascular invasion.     

Esophageal early basaloid squamous carcinoma with unusual narrowband imaging magnified endoscopy findings

Basaloid squamous carcinoma (BSC) is a rare variant of esophageal cancer. There are very few reports of “early” BSC. Here we report a case of early BSC with unusual findings by narrowband imaging magnified endoscopy (NBI-ME). A 70-year-old man with a middle thoracic esophageal tumor was referred to our hospital. White-light endoscopy revealed a reddish depressed lesion 5 mm in diameter having a subepithelial tumor-like prominence with a gentle rising slope. NBI-ME revealed irregular loop-shaped microvessels coexistent with thick irregularly branched non-looped vessels. Iodine staining revealed a pale brown lesion. We performed endoscopic submucosal dissection for diagnostic treatment. Histologic examination showed the proliferation of basal cell-like hyperchromatic tumor cells in the lamina propria and with slight invasion into the submucosa at a depth of 320 μm. The tumor cells formed solid nests and microcystic structures, containing an Alcian blue-positive mucoid matrix. The surface was covered with squamous epithelium without cellular atypia. Thin vessels were observed in the intra-epithelial papilla and thick vessels were observed around the solid nests beneath the epithelium. Based on these findings together, we diagnosed the lesion as BSC. In this case, the NBI-ME findings differed from those of typical squamous cell carcinoma in that both non-invasive cancer-like irregular loop-shaped microvessels coexisted with massively invasive cancer-like thick non-looped vessels. We speculate that the looped and non-looped vessels observed by NBI-ME histologically corresponded to thin vessels in the intra-epithelial papilla and thick vessels around the tumor nests, respectively. These NBI-ME findings might be a feature of early esophageal BSC.     

Pathomorphology of esophageal and gastric varices

In this article, the gross pathology of varices and supplying veins are described comparing esophageal varices and varices of the cardia and fundus of the stomach. The angioarchitecture of the lower esophagus is such that normally very thin parallel veins in the lamina propria mucosae in the palisade zone become enlarged in portal hypertension and join the few larger submucosal veins to form esophageal varices. Enlarged parallel veins come to pile up and join the submucosal veins at an acute angle, rendering this area vulnerable to rupture. Most ruptures occur in this critical area. The basic differences between esophageal and gastric varices are the layers in which the varicose veins form: the lamina propria mucosae and submucosa in the esophageal varices and the submucosa in gastric varices. While cardiac veins and varices are continuous with esophageal varices, fundic varices develop independently as part of a splenogastrorenal shunt that runs through the stomach wall, having rare communications with other veins. The fundic varix is so large in caliber that when it ruptures, the muscularis mucosae and lamina propria are penetrated with massive bleeding. The treatment of varices calls for complete thrombosis of all varicose veins, and merits and demerits of available treatment modalities are discussed based on autopsies from the pathologic point of view. Because of the large size, the management of fundic varices is difficult, and the new technique called balloon-occluded retrograde transvenous obliteration for occluding fundic varices is discussed.     

Endoscopic Resection of Gastric Plasmacytoma

Gastric plasmacytoma is a rare form of extramedullary plasmacytoma. It is usually diagnosed with a barium meal or endoscopy for various gastrointestinal symptoms. Most gastric plasmacytomas are treated by surgical resection, even when they are confined to gastric mucosal lamina propria or submucosa, that is, in the early stages. We present here a case of gastric plasmacytoma showing an endoscopic feature of submucosal tumor approximately 2.5 cm in diameter, found through an X‐ray study in a mass screening. Endoscopic ultrasonography revealed a hypoechoic tumor located in the submucosal layer, and the tumor appeared to be safely excised by routineendoscopic resection. In order to obtain histlogical diagnosis, we resected the tumor, which was diagnosed as a plasmacytoma. The patient did not shown any sign of local and/or generalized recurrence during follow up for 2.5 years. We have not found a successful case of endoscopic resection of gastric plasmacytoma reported previously.     

Collateral vessels around the esophageal wall in patients with portal hypertension: comparison of EUS imaging and microscopic findings at autopsy

BACKGROUND: In patients with portal hypertension, EUS reveals the presence of collateral vessels within and outside the esophageal wall such as esophageal varices, periesophageal collateral veins (peri-ECVs), paraesophageal collateral veins (para-ECVs), and perforating veins. This study retrospectively compared radial EUS images of these collateral vessels with histopathologic findings. METHODS: Four patients with esophageal varices treated by endoscopic injection sclerotherapy were studied. EUS was performed to evaluate the effects of endoscopic injection sclerotherapy. After endoscopic injection sclerotherapy, the segment of the esophagus from the esophagogastric junction to a point 5 cm proximal to junction was imaged with a 20-MHz radial scanning catheter US probe. Esophageal collateral veins outside the esophageal wall were identified as peri-ECVs (veins lateral to muscularis propria or within adventitia) and para-ECVs (veins lateral and separate from muscularis propria) along with perforating veins (veins connecting extramural collateral veins to submucosal varices). At autopsy, the esophagus with surrounding tissue was removed and cross-sectioned at 1-cm intervals from the esophagogastric junction to a point 5 cm proximal to the junction. Radial EUS images were correlated with histopathologic findings. RESULTS: Radial EUS after endoscopic injection sclerotherapy demonstrated peri-ECVs and perforating veins in all cases and para-ECVs in 3 cases. Based on histopathologic findings, veins associated with the esophageal wall were divided into 3 groups: those adjacent to the muscularis propria, veins separated from the wall without contact with the muscularis propria, and veins perforating the muscularis propria. All 3 groups of veins were observed in all cases. These 3 types of veins identified by histopathologic examination corresponded, respectively, to the peri-ECVs, para-ECVs, and perforating veins observed by EUS. CONCLUSION: Collateral esophageal veins demonstrated by radial EUS in patients with portal hypertension correspond to collateral veins identified histopathologically. In patients with portal hypertension, EUS is useful for assessment of vascular anatomy around the esophageal wall.     

Endoscopic resection in the treatment of intramural esophageal bronchogenic cysts: A retrospective analysis of 17 cases

BackgroundIntramural esophageal bronchogenic cysts (EBCs) are rare congenital malformations. Differences in reports on the clinical features of intramural EBCs and some controversies about the treatment strategy for intramural EBCs exist.ObjectivesTo investigate the clinical characteristics of intramural EBCs and evaluate the safety and efficacy of endoscopic resection.MethodsThe clinical and endoscopic features, endoscopic resection treatment, postoperative adverse events, and follow-up results of 17 patients with intramural EBCs were retrospectively studied.ResultsIntramural EBCs exhibited male predominance with a male/female ratio of 58.8% (10/7) and were predominantly found in the distal esophagus. Approximately 94.1% of patients presented with gastrointestinal symptoms. All lesions were protruding masses covered by intact mucosal epithelium. The morphologies of intramural EBCs were diverse under white light endoscopy. On endoscopic ultrasonography, intramural EBCs presented as homogeneous or inhomogeneous hypoechoic or anechoic lesions. Eleven lesions originated from the muscularis propria, which underwent submucosal tunnel endoscopic resection (STER), and six lesions were from the submucosa, which underwent endoscopic submucosal dissection (ESD). Approximately 88.2% of patients underwent complete endoscopic resection. No serious pneumothorax, bleeding, pleural effusion, esophagotracheal fistula, or other adverse events occurred in all patients after endoscopic resection, and no cyst recurrence, metastasis, or esophageal scar stenosis was observed during the follow-up period.ConclusionsIntramural EBCs can be treated by digestive endoscopic surgery. STER and ESD are safe, effective, and minimally invasive resection methods.     

Treatment Strategy after Endoscopic Resection of Superficial Esophageal Squamous Cell Carcinoma: A Single Institution Experience

Background/Aims

The aim of this study was to analyze and propose a treatment strategy after endoscopic resection of superficial esophageal squamous cell carcinoma in a single institution.

Methods

This is a retrospective review of 37 patients who were treated by endoscopic resection during a 6-year period.

Results

The mean tumor size was 11.5±5.5 mm (range, 3 to 31 mm). Thirty-one lesions (83.8%) were treated by endoscopic submucosal dissection, and six lesions were treated by endoscopic mucosal resection (16.2%). The en bloc resection rate and complete resection rate were 91.9% and 81.8%, respectively. The tumor invasion depth was diagnosed as epithelial in five cases (13.5%), lamina propria mucosa in 12 cases (32.4%), muscularis mucosa in 10 cases (27.0%) and submucosa in 10 cases (27.0%). The complication rate was 13.5% and included three cases (8.1%) of perforation. Ten patients who had muscularis mucosa and submucosa lesions received additional treatments, including six patients who were treated with esophagectomy, three patients who were treated with radiotherapy and one patient who was treated with chemoradiotherapy. One patient with lamina propria lesions received radiotherapy due to a positive resection margin. The median follow-up duration was 22 months (range, 4 to 79 months), and no recurrence or metastasis was noted during follow-up.

Conclusions

Tailored management after endoscopic treatment of superficial esophageal squamous cell carcinoma can offer an acceptable oncologic outcome in early esophageal carcinoma.     

Submucosal tunnelling endoscopic resection for the treatment of esophageal submucosal tumours originating from the muscularis propria layer: An analysis of 15 cases

Background and aimsThe aim of this prospective study was to evaluate the feasibility of submucosal tunnelling endoscopic resection of esophageal tumours originating from the muscularis propria layer.MethodsFifteen patients with esophageal submucosal tumours originating from the muscularis propria layer underwent submucosal tunnelling endoscopic resection between August 2011 and February 2012. The key steps were: (1) creating a submucosal tunnel from 5 cm above the tumour between the submucosal and muscular layers with a hook knife or hybrid knife; (2) dissecting the tumour by the technique of endoscopic submucosal dissection; (3) closing the mucosal incision site with clips after the tumour was removed.ResultsSubmucosal tunnelling endoscopic resection was successfully performed in all cases. The en bloc resection rate was 100%. The average tumour diameter was 1.8 cm (range 1.0–3.0 cm). During the procedure, perforation occurred in 3 patients, who recovered after conservative treatment. No residual tumour or tumour recurrence was detected during the follow-up period (mean: 3.5 months, range: 1–9 months). Pathological diagnoses of these tumours were leiomyomas (12/15) and gastrointestinal stromal tumours (3/15).ConclusionsSubmucosal tunnelling endoscopic resection is a feasible method for the treatment of small esophageal submucosal tumours originating from the muscularis propria layer.     

食管黏膜下肿物的特性以及超声内镜的诊断和治疗意义

背景：食管病变内镜下或手术治疗的风险均较高,术前准确判断病变的层次和性质,对决定手术的方式十分重要。目的：探讨食管黏膜下肿物的特性以及超声内镜对食管黏膜下肿物的诊断、治疗意义。方法：由内镜检查发现的116例食管黏膜下肿物患者行超声内镜检查,并给予相应的切除治疗,总结超声内镜下食管黏膜下肿物的特性。结果：超声内镜下88例（75．9％）食管黏膜下肿物的直径〈1cm,104例（89．7％）病变起源于黏膜肌层,多数（85．3％）表现为低回声或混合偏低回声的声像图。80例接受切除治疗,其中67例（83．8％）行EMR治疗,肿物直径〈1cm者占89．6％,局限于黏膜肌层占97．0％。组织病理学分析表明食管黏膜下肿物以平滑肌瘤最为常见（86．3％）。超声内镜诊断与病理诊断的符合率约为82％。结论：大多数食管黏膜肌层起源的肿物行EMR治疗简便、安全,对于较大的病灶,或起源于固有肌层者ESD仍是一种安全有效的方法。超声内镜可判断食管黏膜下肿物起源并进行定性诊断,从而指导临床合理选择黏膜下肿物的治疗方法。     

Preoperative Iodine Staining May Complicate the Demarcation of Esophageal Carcinoma

A 53-year-old man was suspected of having an esophageal neoplasm. An endoscopic examination including Lugol chromoendoscopy suggested an esophageal squamous cell neoplasm limited to the lamina propria. A targeted biopsy showed atypical squamous cells, and an endoscopic submucosal dissection was performed 22 days after the previous endoscopy. Although a single 40 mm unstained area was observed by preoperative Lugol chromoendoscopy, intraoperative endoscopy revealed a 25 mm iodine-unstained area, with small unstained areas scattered on the oral side. We included the small unstained areas in the extent of the resection through assessment by preoperative endoscopy. Histopathologically, the tumor extent appeared to coincide with the preoperative assessment. Tumor cells were found in the basal-parabasal layers of the mucosa, in which small unstained areas were scattered, although the superficial layers exhibited well-differentiated cells containing glycogen in the cytoplasm. Although Lugol chromoendoscopy, which can induce chemical esophagitis, is widely used, re-epithelialization after mucosal damage by preoperative iodine staining may complicate the intraoperative demarcation of tumors.     

Evolving field of third-space endoscopy: Derivatives of peroral endoscopic myotomy

Third-space endoscopy, also known as submucosal endoscopy, allows for a wide range of therapeutic interventions within the submucosal layer and even into the muscular or subserosal layers of the gastrointestinal lumen. The technical development of peroral endoscopic myotomy (POEM) for achalasia has revolutionized the field of therapeutic endoscopy and the method has been continuously refined and modified. Although POEM has been applied to treat primary achalasia, it shows a favorable clinical response in other esophageal motility disorders and as a salvage treatment after previously failed intervention. Gastroesophageal reflux after POEM has drawn considerable attention and there have been major advancements in its prevention and management. POEM has led to advantageous derivatives such as peroral endoscopic tumor resection or submucosal tunneling endoscopic resection for resection of subepithelial lesions, Zenker POEM for hypopharyngeal diverticula, diverticular POEM for epiphrenic esophageal diverticula, and gastric POEM for refractory gastroparesis. These techniques have a similar concept, which constitutes submucosal tunneling with a mucosal flap valve and secure mucosal incision closure. The submucosal tunneling technique is widely accepted and continues to evolve. This study aimed to review in detail the indications, outcomes, and technical variations in POEM and explore several emerging submucosal tunneling procedures. This review will benefit future studies by providing a summary of recent developments in this field.     

源于固有肌层的胃间质瘤行内镜下切除闭合术的可行性研究

目的 评价对来源于固有肌层的非腔内生长型胃间质瘤施行内镜下切除闭合术治疗的可行性.方法 46例患者经胃镜和超声内镜检查诊断为起源于固有肌层的非腔内生长型胃黏膜下肿瘤,采用内镜下切除闭合术切除肿瘤,行常规病理及免疫组化检查后证实为间质瘤.术后内镜随访,观察治疗效果及有无并发症.结果 46例非腔内生长型胃间质瘤经内镜下切除闭合术治疗后均完全切除,切除后2例保留完整的浆膜层,44例术中遗留切口,切口最大径1.5 cm,行钛夹夹闭切口,予抑酸、胃肠减压、静脉应用抗生素等辅助治疗.病理报告全层切除46例,肿瘤直径为0.5～3.7 cm.44例患者术后48～72 h后进食,未见明显不适;2例术后出现气腹、局限性腹膜炎,其中1例切口1.5 cm患者术后第2天切口裂开,再次钛夹夹闭裂开切口,辅助治疗10～12 d,该2例患者痊愈出院.术后6个月随访,所有患者切口均形成白色溃疡瘢痕.结论 对于非腔内生长型胃间质瘤,内镜下切除闭合术是一种安全、经济、创伤小的治疗方式,值得临床推广.     

Long-term outcome after endoscopic mucosal resection in patients with esophageal squamous cell carcinoma invading the muscularis mucosae or deeper

BACKGROUND: Endoscopic mucosal resection is recommended for squamous cell carcinoma of the esophagus confined to the lamina propria. However, endoscopic mucosal resection is often performed in patients with tumors that invade the muscularis mucosa or upper submucosa to minimize surgical invasiveness, despite the increased risk of lymph node metastasis. This study prospectively evaluated long-term outcome in such patients. METHODS: Twenty-six consecutive patients with squamous cell esophageal carcinoma invading the muscularis mucosa or submucosa who underwent endoscopic mucosal resection from June 1992 through March 2000 (extended endoscopic mucosal resection group) were studied. As control group, 44 consecutive patients with esophageal carcinoma invading the muscularis mucosae or upper third of the submucosa and no preoperative evidence of lymph node metastasis who underwent esophagectomy during the same period (surgical resection group) were studied. RESULTS: Overall survival rates at 5 years in the extended endoscopic mucosal resection group and surgical resection group were, respectively, 77.4% and 84.5%. There was no significant difference between survival distributions. Cause-specific survival rates at 5 years in extended endoscopic mucosal resection and surgical resection groups were, respectively, 95.0% and 93.5%. Survival curves for the groups were similar. CONCLUSION: Although patients were not randomized to extended endoscopic mucosal resection or surgical resection in this study, the results suggest that endoscopic mucosal resection may be safe and effective for management of squamous cell esophageal carcinoma invading the muscularis mucosae or upper submucosa.     

Curative endoscopic ultrasound-assisted submucosal resection of a gastric stromal tumor

Endoscopic submucosal resection has been proposed as a feasible alternative for the diagnosis and treatment of small submucosal tumors (< 3 cm), as compared to classic interventions (surgical intervention or frequent follow-up). Therapeutic options should be established after precise endoscopic ultrasound assessment of the tumor characteristics. We present the case of a 60 year-old patient, admitted to the Emergency Department for upper gastrointestinal (GI) bleeding. Upper GI endoscopy showed a submucosal tumor on the posterior gastric wall, with hyperemic covering mucosa, without central ulceration. Endoscopic ultrasound identified a 10-mm well-delimited hypoechoic lesion, with the origin in the third hyperechoic layer (submucosa). After injection of 1:10000 epinephrine in the submucosa, with subsequent elevation of the protrusive formation, we performed an endoscopic submucosal resection without any complications. Pathology exam showed a gastric stromal tumor with low mitotic activity, the endoscopic resection being considered curative. The absence of independent risk factors determined by ultrasound endoscopy (size > 3 cm, irregular margins, hyperechoic foci > 3 mm, cystic spaces > 4 mm, presence of intratumoral Doppler signal), as well as the low mitotic activity, permitted the subsequent follow-up of the patient. A control endoscopic examination performed after 4 weeks showed the healing of the post-resection ulceration. In conclusion, ultrasound endoscopy allowed the establishment of a correct presumptive diagnosis and the subsequent assistance of endoscopic submucosal resection, used for pathological confirmation and for curative endoscopic treatment.     

The three-dimensional microstructure of intramural lymphatics in the canine large intestine

The three-dimensional microstructure of the intramural lymphatics of canine large intestine was clarified micrographically. After direct injection of India ink into the colon wall, we prepared 2<3cm fullthickness transparent specimens of the opened colon wall and transparent sections. Lymph vessels were distinguished from blood vessels by intraarterial injection of cinnabar ink. A stereomicroscope was used for observation, and stereograms were reproduced. Lymph vessel networks were present in the shallow and deep layers of the lamina propria mucosae and the deep layer of the submucosa. The lymph vessel networks in the lamina propria mucosae were present immediately beneath the blood capillary networks. The thickest lymph vessels and the densest network appeared in the submucosa. From the submucosa, some of the lymph vessels existed immediately to merge into the collecting trunks and other lymph vessels which compose a minor pathway existed along lymph vessels in the muscular layer and finally merged into the collecting trunks in the subserosa.     

The three-dimensional microstructure of intramural lymphatics in the canine large intestine

The three-dimensional microstructure of the intramural lymphatics of canine large intestine was clarified micrographically. After direct injection of India ink into the colon wall, we prepared 2 less than 3cm full-thickness transparent specimens of the opened colon wall and transparent sections. Lymph vessels were distinguished from blood vessels by intraarterial injection of cinnabar ink. A stereomicroscope was used for observation, and stereograms were reproduced. Lymph vessel networks were present in the shallow and deep layers of the lamina propria mucosae and the deep layer of the submucosa. The lymph vessel networks in the lamina propria mucosae were present immediately beneath the blood capillary networks. The thickest lymph vessels and the densest network appeared in the submucosa. From the submucosa, some of the lymph vessels existed immediately to merge into the collecting trunks and other lymph vessels which compose a minor pathway existed along lymph vessels in the muscular layer and finally merged into the collecting trunks in the subserosa.     

环扫超声内镜术前评估对食管上皮下肿物内镜治疗的意义

目的探讨环扫超声内镜(EUS)术前评估对食管上皮下肿物内镜治疗的意义。方法选取内镜发现食管上皮下肿物并行内镜下或外科手术治疗的患者30例,麻醉状态下行环扫EUS术前评估。食管上皮下肿物内镜下治疗可选择不同内镜下手术方式,黏膜肌层病变非气管插管麻醉行内镜下黏膜切除术(endoscopic mucosal resection,EMR);黏膜下层、固有肌层病变气管插管麻醉行内镜黏膜下隧道肿瘤切除术(submucosal tunneling endoscopic resection,STER)或外科手术。结果20例术后诊断为黏膜肌层病变中,19例术前环扫EUS明确诊断,1例术前诊断为固有肌层病变;8例术后诊断为固有肌层病变及2例黏膜下层病变中,术前环扫EUS均明确诊断。Weighted Kappa评价显示,点估计0.92268,95%CI估计0.77431~1.00000,提示环扫EUS诊断与术后内镜下诊断一致性优秀。结论环扫EUS对食管上皮下肿物层次定位有较高的可靠性,对手术方式及麻醉方式的选择有指导意义。检查可在患者麻醉状态下完成,检查过程较舒适。     

Offshoots of peroral endoscopic myotomy: Submucosal tunneling endoscopic resection,pyloromyotomy, and beyond

The emergence of peroral endoscopic myotomy (POEM) marks the rising of a new branch of therapeutic endoscopy. Our group defines it as tunnel endoscopic surgery that includes several novel procedures utilizing a submucosal tunnel as an operating space. In 2010, we developed a new procedure that takes advantage of the submucosal tunneling technique popularized by POEM to achieve complete, full-thickness endoscopic resection of upper gastrointestinal submucosal tumors originating from the muscularis propria layer. Our group coined the acronym STER (submucosal tunneling endoscopic resection) for this procedure. Herein, we summarize this novel method and other offshoots of POEM.     

Submucosal tunneling endoscopic resection for simultaneous esophageal and cardia submucosal tumors originating from the muscularis propria layer (with video)

Submucosal tunneling endoscopic resection (STER) is a new treatment technique for upper gastrointestinal submucosal tumors (SMT) originating from the muscularis propria (MP) layer. In contrast to conventional endoscopic resection, the new therapy can maintain the mucosal integrity of the digestive tract, which effectively prevents mediastinitis and peritonitis. STER, although a known method, has not been widely adopted because of technical difficulties. Here, we describe the case of a 30‐year‐old patient presenting with two separate SMT originating from the esophageal and cardia MP layer. A 2‐cm longitudinal mucosal incision was made approximately 5 cm proximal to the esophageal SMT, and the esophageal and cardia SMT were dissected successively in the same submucosal tunnel. In the relevant literature, this is the first case of STER for resecting esophageal and cardia SMT using the same submucosal tunnel.