Post written by Sonmoon Mohapatra, MD, from the Division of Gastroenterology and Hepatology, Saint Peter’s University Hospital/Rutgers—RWJ Medical School, New Brunswick, New Jersey, USA.

A 62-year-old morbidly obese (BMI 62) man with multiple comorbid conditions was found to have a 1.5-cm subepithelial duodenal lesion in the anterior wall of the duodenal bulb, located within 1 to 2 mm from the pyloric ring during the surveillance endoscopy for Barrett’s esophagus. Endoscopic ultrasound showed a 15.5- x 11.8-mm hypoechoic lesion in the duodenal bulb arising from the submucosal layer. Pathologic examination showed well-differentiated NET. CT abdomen and pelvis with intravenous contrast did not show any evidence of lymph node or distant metastasis. After a multidisciplinary discussion, the recommendation was to attempt endoscopic resection due to the patient’s underlying medical comorbidities. Because of the larger size and location of the lesion, a decision was made to pursue ESD. The procedure was performed under general anesthesia. The area around the lesion was injected with mixed solution of hetastarch and methylene blue. ESD was technically challenging given that the proximal end of the lesion was in close proximity to the pylorus and the narrow submucosal space. The mucosal incision was started from the proximal site of the lesion with the use of a 1.5-mm DualKnife (Olympus America, Center Valley, Pa, USA). Using a short-type ST hood (Fujifilm Co., Tokyo, Japan) and saline immersion technique, the narrow submucosal space was successfully exposed, and a hook knife was used to allow precise dissection and avoid muscle injury. The tumor was completely dissected of the duodenal wall in en bloc fashion. The specimen measured 1.5 cm in diameter. The postprocedural course was uneventful. He was discharged on a 4-week course of proton pump inhibitor.

Endoscopic submucosal dissection (ESD) in the duodenum is technically difficult because of the thinner duodenal wall and poor maneuverability of the endoscope due to the sharp angulation of the duodenum. While well-differentiated, nonfunctional duodenal NETs that are limited to the mucosa/submucosa, up to 10 mm in size can be endoscopically removed; the optimal management of duodenal NETs 10 to 19 mm in size is still controversial. In our case with the large lesion adjacent to the pyloric ring, saline immersion technique and short-type ST hood cap was used which helped to successfully expose the narrow submucosal space and open the cutting edge of the mucosa.

ESD can be considered for a duodenal NET (lesion size 10-19 mm) that would otherwise be not amenable for EMR or full-thickness resection device. Saline immersion technique and use of ST hood facilitate the procedure by means of floating effect of the opening of the mucosal flap against gravity and allow easier approach to the narrow space between the lesion and pyloric ring.

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