You are missing it!!!

This patient is undergoing a set of oesophageal dilatations of a radiotherapy induced stricture. Three set of samples, a total of 18 biopsies have been obtained from the stricture which have all been reassuring. A CT has reported: "Distal oesophageal mural thickening extends throughout the length of the previously demonstrated bulky oesophageal tumour. No focal abnormality to suggest recurrent disease and presumably appearances are all radiotherapy related".  In the video clip, the stricture is seen to be dilated to 20mm. 

WHAT WOULD YOU DO NEXT

■ Organise the next dilatation in a weeks time

She WILL need more dilatations but you've missed something important!

■ Take another set of samples from that stricture

It does look concerning still but there is something even more concerning here!

■ Take another set of samples from the more proximal oesophagus

You've spotted it!

■ Take samples at the distal oesophagus (below the stricture)

That odd, fleshy lump at 6 O'clock below the stricture has been sampled already. More samples is never wrong but there is something even more important to sample first!

explanation

On intubation, I glimpsed something just below the upper oesophageal sphincter. I deliberately didn't dwell on it in the video, simulating the previous intubations when a synchronous lesion had been missed. In the explanatory clip below, you get a better view of her second SCC. CT staged the second lesion as no worse than T2, N0. 

The moral of the story?  It's when we are distracted that we run the risk of missing things! In this case, the previous endoscopists had approached the endoscopy as a case of dilatation and switched off their eyes!