Post written by Tomoaki Tashima, MD, PhD, from the Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan.
A 58-year-old man was found to have a flat-elevated lesion of 20 mm in size in the second portion of the duodenum. We selected endoscopic submucosal dissection (ESD) for en bloc resection because endoscopic mucosal resection was deemed too difficult due to poor maneuverability of the endoscope and poor submucosal elevation of the lesion upon injection. The lesion was resected en bloc without adverse events, and the mucosal defect was approximately 30 mm in size. However, closure of the post-duodenal ESD mucosal defect using endoclips would not be easy due to the size of the mucosal defect and poor maneuverability of the endoscope. Therefore, we tried to perform endoscopic closure assisted by EndoTrac (Top Corporation, Tokyo, Japan). First, the endoclip that had been fixed to EndoTrac was deployed at the distal margin of the mucosal defect. The sheath of EndoTrac was pulled proximally in an attempt to close the mucosal defect; however, the mucosal defect unexpectedly became enlarged. The tip of the sheath was advanced toward the margin of the mucosal defect by pulling the handle; then, the sheath was pushed distally, contrary to the initial attempt. After this procedure, both sides of the mucosal defect were successfully gathered together. Additional endoclips were deployed to achieve complete closure of the defect. The endoclip that had been fixed to Endotrac was removed by a grasping forceps. Five days after duodenal ESD, endoscopy showed that all endoclips were still in place. Histopathological examination revealed that the lesion was high-grade dysplasia with negative margins.
In duodenal ESD, exposure of the post-ESD mucosal defect to pancreatic juice and bile acid induces delayed perforation and bleeding. Complete closure of the mucosal defect seems effective in preventing such severe adverse events. Various endoscopic closure methods after duodenal ESD were reported. We developed a new closure method using EndoTrac (Top Corporation, Tokyo, Japan). EndoTrac was originally developed as a traction device for safe, effective ESD with a function of freely changing the direction of traction. This technique demonstrated a new application of EndoTrac. One merit of EndoTrac is that the procedure of using EndoTrac is very simple and can be performed with a single-channel endoscope. Furthermore, EndoTrac has been not only used as a traction device in its original method of use, but also applied in a surgical technique similar to so-called endoscopic endoloop closure of mucosal defect by utilizing the tip of EndoTrac.
In our case, by leveraging the unique feature of EndoTrac in which the direction of traction is adjustable, it was possible to facilitate endoscopic closure by using endoclips, even in locations where maneuverability of the endoscope is limited and the usual traction force is unavailable.
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