Extensive (8 to 12 cm2) Noncircumferential Endoscopic Mucosal Resection for Early Esophageal Cancer Philippe Monnier, MD, Yves Jaquet, MD, Alexandre.

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Extensive (8 to 12 cm2) Noncircumferential Endoscopic Mucosal Resection for Early Esophageal Cancer Philippe Monnier, MD, Yves Jaquet, MD, Alexandre Radu, MD, Raphaelle Pilloud, MD, Pierre Grosjean, MD, Anette Escher, MD, Elsa Piotet, MD, Snezana Andrejevic Blant, MD The Annals of Thoracic Surgery Volume 89, Issue 6, Pages S2151-S2155 (June 2010) DOI: 10.1016/j.athoracsur.2010.03.074 Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig. 1 Rigid esophagoscope for endoscopic mucosal resection: (A) the diagnostic esophagoscope has an inner tube that seals the distal aperture of the outer tube (see close-up view) and is used as a conventional rigid esophagoscope, with a remote control for inflation, suction and irrigation. (B) Resectoscope mounted on the outer shaft of the diagnostic esophagoscope. The transparent, perforated window and the diathermy loop are seen in the close-up view. Mucosal resection is carried out from distal to proximal. The Annals of Thoracic Surgery 2010 89, S2151-S2155DOI: (10.1016/j.athoracsur.2010.03.074) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig. 2 Principle of endoscopic mucosal resection with the rigid esophagoscope: Negative pressure is applied to the inside portion of the resectoscope, and under visual control, the esophageal mucosa is sucked against the transparent window at a predetermined depth. Resection with a diathermy wire loop (dashed line) is performed at a regular depth through the submucosa in less than 10 seconds. (LMM = lamina muscularis mucosae; MPE = muscularis propria externa; MPI = muscularis propria interna). The Annals of Thoracic Surgery 2010 89, S2151-S2155DOI: (10.1016/j.athoracsur.2010.03.074) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Resected specimen for intramucosal adenocarcinoma arising in Barrett's esophagus, with superimposed histological mapping: the extent of Barrett's esophagus is outlined in white, low grade dysplasia in hatching, high grade dysplasia in light grey, and superficial adenocarcinoma in grey. The Annals of Thoracic Surgery 2010 89, S2151-S2155DOI: (10.1016/j.athoracsur.2010.03.074) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Histology of the resected specimen displayed in Fig. 3 (hematoxylin-eosin staining): (A) Long-segment mucosal resection (2× original size): the thickness is fairly constant over the length of the resected specimen, except at both extremities. (B) (10× magnification) and (C) (20× magnification). Close-up views of high-grade intraepithelial neoplasia and early adenocarcinoma at different levels. The lamina muscularis mucosae is conspicuous in the close-up views and the deep resection margins at the submucosal level are clear. The Annals of Thoracic Surgery 2010 89, S2151-S2155DOI: (10.1016/j.athoracsur.2010.03.074) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions