Post written by Anand R. Kumar, MPH, MD, from the Division of Gastroenterology, Thomas Jefferson University, Philadelphia, Pennsylvania.

A young man presented with an incidental 35-mm ampullary neuroendocrine tumor detected on upper endoscopy. We chose to do an underwater ampullectomy and obtained negative margins.

Endoscopic ampullectomy is an advanced procedure with variable techniques. The underwater EMR technique is not one of them. The safety of this technique has been shown in the colon and duodenum. We used this video to show its effectiveness and safety for ampullectomy. We also think this may be a superior technique for ampullectomy compared to submucosal injection or gas insufflation especially for sub-epithelial lesions, and we demonstrated that in the form of a sketch included in the video and the manuscript.

We hope to highlight the physics of water immersion and how endoscopists can use that to their advantage in removing large lesions with relatively simple tools. In addition, we also demonstrated usage of clips around the ampulla with a forward viewing endoscope and a distal attachment, which is another area where most of us struggle with a side-viewing duodenoscope.

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