Post written by Borathchakra Oung, MD, from the Department of Endoscopy and Gastroenterology, Edouard Herriot Hospital, Lyon, France.

Managing lesions endoscopically in the duodenum can be challenging due to its thin wall and anatomically narrow lumen that limit endoscope maneuver. We reported a case of a subepithelial neuroendocrine tumor located in duodenal bulb just behind the pylorus arch, which was effectively resected by endoscopic submucosal dissection with double clips and rubber band traction (DCT-ESD). Our traction system helped us to improve visualization of the submucosal cutting line and the endoscope positioning by pulling gradually the cut specimen away from the pylorus arch.

ESD was invented to deal with large lesions in gastrointestinal tract. However, it requires advanced endoscopic skill and experiencesto perform effectively and safely. Nevertheless, in the duodenum, the indication of ESD is still limited due to the safety concern. We believe that adding a traction system such as ours would help endoscopists perform this procedure more efficiently, safely, and faster. Through our case, we have shown that DCT-ESD allows us to achieve complicated resection of this subepithelial lesion.

A full-thickness resection device (FTRD) could be another option in this situation even though it is not yet approved for foregut lesion and has a high cost. Meanwhile, endoscopic resection should be taken into account depending on the endoscopist’s expertise. For this particular potential lesion, we suggest performing DCT-ESD to assure curative resection. It is not time consuming and not financially burdensome.

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