Post written by Osamu Dohi, MD, PhD, from the Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.

An 84-year-old woman had a circumferential SNADET that was detected during esophagogastroduodenoscopy. We performed laparoscopy and endoscopy cooperative surgery (LECS) with ESD technique and laparoscopic closure for the SNADET.

First, we performed endoscopic resection using the ESD technique, with the patient under general anesthesia. We incised the mucosa and dissected the submucosal layer using the pocket-creation method with a scissors-type knife (Clutch Cutter; Fujifilm Co, Ltd, Tokyo, Japan). We created 2 oral-to-anal submucosal tunnels on the sides of the anterior and posterior walls. After completing the circumferential mucosal incisions on both the oral and anal sides, we performed submucosal dissection between the 2 tunnels and achieved en-bloc resection. The length of the mucosal defect was approximately 15 cm; it was easily identified from the serosal side. A circumferential full-thickness hand-sewn suture laparoscopically reinforced the duodenal wall to prevent delayed perforation.

Then, we performed gastrojejunostomy because duodenal stenosis after suturing the mucosal defect was expected to occur as a result of scarring of the remaining mucosal defect. The patient had a good postoperative clinical course and experienced no adverse events. The pathologic diagnosis was intramucosal tubular adenocarcinoma with negative horizontal and vertical margins, and resection was determined to be curative.

A circumferential adenocarcinoma on the duodenum is challenging for ESD even with assistance of laparoscopic surgery because the duodenal wall is very thin and endoscopic maneuverability is very poor. We described how to perform laparoscopy and endoscopy cooperative surgery (LECS) for this kind of difficult lesion with ESD technique and laparoscopic closure. Complete closing of mucosal defect after duodenal ESD is essential for preventing delayed adverse events. Various endoscopic closures after duodenal ESD were reported. However, complete closure of large mucosal defect more than 10 cm in size after circumferential ESD cannot be performed endoscopically. Therefore, a circumferential full-thickness hand-sewn suture was laparoscopically implanted in the duodenal wall for reinforcement. However, circumferential suturing was identified as a risk of duodenal obstruction.

We successfully performed LECS for a circumferential adenocarcinoma on the duodenum. However, this treatment has not been established as a standard surgery regarding safety and feasibility. Therefore, more cases are needed to confirm the safety and feasibility of LECS for a circumferential duodenal tumor.

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