Post written by Tomoaki Tashima, MD, PhD, from the Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan.
A 74-year-old man was referred to our institute for the treatment of a large flat-elevated tumor (diameter, 50 mm) in the duodenal bulb. We selected ESD for the en bloc resection of the lesion, and the patient underwent the procedure under general anesthesia. The procedure was performed using a therapeutic endoscope (GIF-H290T; Olympus, Tokyo, Japan). After injecting hyaluronic acid, we made an initial mucosal incision and performed slight submucosal dissection on the proximal side of the tumor in the forward view using a DualKnife J. We then performed a submucosal dissection of the tumor’s posterior wall side in the forward view using a Clutch Cutter to create a mucosal flap. It was unfeasible to reach and dissect the anterior wall-side of the tumor in the forward view due to poor endoscope maneuverability. Therefore, we switched to the retroflexed view and made a circumferential incision. A slight submucosal dissection was performed continuously using the DualKnife. Subsequently, a clip and thread were deployed to the center of the tumor’s distal edge for traction. The thread outside the patient’s body was pulled proximally, and submucosal dissection was performed continuously. However, as the tumor was gradually dissected, we discovered that a single traction was insufficient for maintaining good visualization of both edges of the submucosal layer at the tumor site. Therefore, 2 additional clip-and-threads were deployed to the right and left distal edges of the specimen, which allowed for a safe submucosal dissection with accurate visualization. We maintained traction by using the syringe weight or by gently pulling each thread proximally. The tumor was completely removed in 65 minutes. The mucosal defect extended nearly two-thirds of the way along the duodenal bulb circumferentially. The patient did not develop any adverse events and was discharged on day 6 following. Pathologically, the tumor was an intramucosal tubular adenocarcinoma with negative margins and no lymphovascular invasion.
Clip-and-thread traction-assisted ESD is useful for treating gastrointestinal lesions and offers shortened operative times and a reduced risk of perforation. Duodenal ESD is technically challenging; a large tumor size and poor endoscopic maneuverability particularly contribute to technical difficulties and intraoperative perforation. In our case, by combining planned multiple clip-and-threads traction, we achieved a successful duodenal ESD for cases with high technical difficulty with a short procedure time.
In this case, we used a new therapeutic endoscope (GIF-H290T). This endoscope has a 9.9-mm outer diameter as well as 210° upward and 120° downward angles. The left-right range of motion when further curved upward was wider than that of the conventional endoscope (GIF-Q260J), making it an excellent endoscope for approachability for areas such as narrow and bent canals. This endoscope was very useful for locating the tumor in duodenal bulb in the present case. Furthermore, we found that multiple clip-and-thread traction-assisted ESD is suitable for excision of large tumors in the duodenal bulb; however, further studies are recommended.
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