Post written by Tomoaki Tashima, MD, from the Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan.

A 52-year-old man was found to have a flat-elevated tumor measuring approximately 10 mm in diameter in the second part of the duodenum. First, the border of the target lesion was marked using the tip of an electrosurgical snare (SnareMaster; 15 mm diameter, Olympus). Then, the endoscope was mounted with a 9-mm OTSC (Ovesco Endoscopy GmbH, Tuebingen), and the lesion, including the marking, was suctioned sufficiently into the cap. The OTSC was successfully deployed outside the marking, creating a pseudo polyp of the target lesion. Then, an endoscopic clip with dental floss was driven into a region near the marking with the target lesion held together with the floss, so as to prevent the resected specimen from flowing toward and getting lost in the small bowel. Finally, the lesion was resected en bloc above the OTSC by an electrosurgical snare, using the Endo Cut mode on the electric generator (ICC200; ERBE Elektromedizin, Tübingen, Germany), without adverse events. The patient was discharged on day 2 after the operation. Histopathological examination revealed the lesion to be a high-grade intraepithelial neoplasia. We observed slight fibrosis in and around the submucosal layer of a duodenal gland. In conclusion, the present case was successfully treated by “EMRO” without any adverse events.

Endoscopic resection (ER) for superficial non-ampullary duodenal epithelial tumors (SNADETs) is technically challenging because of the high risk of severe adverse events, including perforation and bleeding. In particular, ER of SNADETs that cannot be lifted due to pronounced fibrosis associated with preoperative biopsy sampling is very difficult. There is also a higher risk of perforation in these cases. Recently, use of an over-the-scope clip (OTSC) system was reported to be safe and effective for endoscopic closure of iatrogenic gastrointestinal perforations or hemostasis. Therefore, we developed a novel method for ER of SNADETs with fibrosis, in which adverse events such as those mentioned above are avoided by the insertion of an OTSC at the base of the target tumor prior to tumor resection; we call this method “EMRO” (endoscopic mucosal resection using OTSC). Herein, we report our first case of EMRO for a SNADET.

“EMRO” enables sufficient resection including the submucosal layer of SNADETs. Hence, the procedure is considered to be useful, even for lesions that cannot be lifted due to pronounced fibrosis associated with preoperative biopsies. “EMRO” can be considered as a safe and effective treatment modality for relatively small (10 mm in diameter) SNADETs with fibrosis.

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