Endoscopic resection of an early cancer in a Barrett's esophagus

(A) A 4-cm long segment of Barrett's esophagus with a large island of squamous mucosa in its center.
(B) A detailed view of a lesion at the 3 o'clock position.
(C) Same lesion shown in the retroflexed position.
(D) The lesion has been delineated by placing coagulation markers at its outer surface.
(E) The lesion has been elevated by injection of diluted epinephrine solution through a standard sclerotherapy needle.
(F) A transparent cap has been attached to the distal tip of the endoscope and a crescent shaped snare is positioned into the distal ridge of the cap.
(G) Using the coagulation markers for orientation, the lesion is identified and subsequently sucked into the cap.
(H) After closure of the snare, the resulting pseudo-polyp, including the lesion, is pushed outside the cap and removed using electrocoagulation.
(I) The created EMR wound shown in the antegrade position; there is still some mucosal swelling due the submucosal lifting.
(J) EMR wound shown in the retroflexed position, no markers can be identified indicating an endoscopically complete resection; note the mucosal whitening due to the vasoconstrictive effect of the epinephrine solution used for submucosal lifting.
(K) The EMR specimen is subsequently removed from the stomach using retrieval net and pinned down on paraffin to prevent shrinking and curling.
(L) Microscopic view of the specimen showing a well differentiated cancer infiltrating into the deeper layers of the muscularis mucosae, there is no infiltration into the submucosa.