Post written by Hiroyuki Aihara, MD, PhD, FASGE, from the Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA.

Endoscopic submucosal dissection (ESD) allows for en bloc resection of gastrointestinal lesions, which theoretically results in lower recurrence rates. However, ESD in the duodenal bulb is technically challenging because of the thin wall and perpendicular angulation. In this video, we present 2 cases of ESD for resection of submucosal tumors in the duodenal bulb, and we highlight techniques and strategies for successful resection.

The first patient was a 72-year-old male who was found to have a 6-mm carcinoid tumor in the duodenal bulb. The second patient was a 60-year-old female who was found to have a 7-mm gastrinoma in the duodenal bulb. ESD was performed with a needle-type knife (Dual Knife; Olympus America, Center Valley, PA, USA). In the first case, the rubber band traction method was used to provide countertraction, allowing visualization of the submucosal dissection plane. In the second case, a tapered distal attachment cap (ST hood; Fujifilm USA, Stamford, Conn, USA) was used, allowing improved exposure of the submucosal dissection plane. Both lesions were successfully removed in en bloc fashion without adverse events. Final pathologic results showed a 7-mm x 6-mm carcinoid tumor and a 6-mm x 5-mm gastrinoma with negative resection margins. Defect closure using hemoclips was not successful in both cases due to the size of mucosal defects and poor maneuverability. Finally, the defects were successfully closed with a continuous running stitch by using an endoscopic suturing device (Overstitch; Apollo Endosurgery, Austin, TX, USA).

There are several endoscopic treatment options currently available for endoscopic removal of submucosal tumors in the duodenal bulb, including cap-assisted endoscopic mucosal resection (EMR-C), endoscopic submucosal resection with ligation (ESMR-L), and ESD. EMR-C is generally not recommended in the duodenal bulb because of the risk of perforation. ESMR-L might be an alternative treatment option; however, ESD potentially allows better control over resection margins, thereby allowing for en bloc and complete resection for duodenal submucosal tumors. ESD in the duodenal bulb is technically challenging; however, the effective use of countertraction and a tapered tip cap facilitated the safe and successful performance of ESD in both cases. Resection defects should be closed to reduce the risk of delayed perforation.

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