Post written by Yoshimasa Miura, MD, PhD, from the Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan.

This video shows an important point that duodenal folds have wide submucosal spaces but no muscularis. If endoscopists understand these characteristics, duodenal neoplasms can be successfully resected.      

It has been unknown for a long time why we couldn’t enter the submucosa easily at the beginning of endoscopic submucosal dissection (ESD) for duodenal neoplasms. However, considering the anatomical features of duodenal folds with wide submucosal spaces and without muscularis, the initial incision should be made in the middle portion of fold side raised by injection. The tip of the endoscope can be entered easily into the submucosal space, which is different from colonic ESD. 

This knowledge is useful for not only ESD but also other endoscopic treatments. For example, in the case of endoscopic mucosal resection (EMR), endoscopists can obtain good protrusion by injection locally into the folds. However, it can’t be obtained with local injection into the flat part between folds, which makes it difficult to complete endoscopic resection. Moreover, this knowledge is important when we perform underwater EMR without injection as well. Duodenal adenomas are often located on the folds and can be resected easily if endoscopists have this knowledge.

 Endoscopists don’t need to hesitate to resect the duodenal folds because they don’t contain proper muscle layer, and this procedure has an extremely low risk. 

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