Post written by Tomoaki Tashima, MD, PhD, from the Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan.

A 69-year-old woman presented with a flat elevated tumor adjacent to the papilla of Vater (POV). Endoscopic submucosal dissection (ESD) was selected for en bloc resection of the tumor and to determine a definitive pathological diagnosis.

The surgery was performed under general anesthesia with laparoscopic assistance in preparation for severe intraoperative perforation or massive arterial bleeding, which are difficult to resolve with endoscopic treatment.  

We started with ESD, but it was difficult to perform because of poor endoscope maneuverability at the duodenal flexure, where the endoscope slipped out of the lesion area to the proximal side, and the gravity side submerged the lesion.

When unexpected massive bleeding occurred during submucosal dissection, visualizing the lesion and detecting the bleeding point became challenging. Gel immersion endoscopy was then used. CO₂ insufflation was turned off, and the gastric and duodenal lumens were deflated.

Subsequently, we injected gel through the accessory channel and filled the lumen around the tumor. Electrosurgical devices were simultaneously inserted through the accessory channel. Because organ collapse was maintained with lower intraluminal pressure, endoscope maneuverability was stable and a good approach to the lesion was secured, allowing safe submucosal dissection. Bleeding slowed because of the gel’s viscosity. Further injection of the gel resulted in good visualization of the bleeding site, enabling quick and easy hemostasis.

Because the gel was viscous, the stagnation around the tumor was maintained long enough to perform ESD. However, when the submucosa was mostly dissected, as the endoscope could not reach the peripapillary area, we abandoned ESD and converted to resection by using the endoscopic papillectomy technique.

Afterward, most of the gel in the duodenum was suctioned. Thus, we reinserted a side-viewing endoscope (TJF-Q290V; Olympus Medical Systems Corporation, Tokyo, Japan), and the tumor was resected with an electrosurgical snare by using ENDO CUT I (effect 1, duration 4, interval 1). After specimen retrieval, prophylactic mucosal defect closure was attempted using endoscopic clips and 2 over-the-scope clips (Ovesco Endoscopy GmbH, Tübingen, Germany) without POV obstruction.

Then endoscopic nasobiliary drainage and endoscopic nasopancreatic drainage tubes were inserted to prevent delayed bleeding and perforation.

The patient did not develop adverse events and was discharged on postoperative day 14. The tumor was diagnosed as a nonampullary intestinal-type high-grade adenoma with negative margins. The mucosal defect scarred entirely within 2 months, and no residual tumor was identified.

By using various tumor resection techniques, mucosal defect closure methods, and adverse event-prevention approaches, we achieved safe endoscopic treatment and avoided pancreaticoduodenectomy in a technically challenging duodenal case.

The “water pressure method” has recently become the mainstream procedural innovation in duodenal ESD. We should have tried performing this method instead of conventional ESD. However, it was difficult to secure the visual field, as the injected water rapidly mixed with the massive luminal arterial bleeding that occurred during submucosal dissection. Hence, gel immersion was superior to water immersion for this case.

The advantages of using gel immersion during ESD include an easy approach to the submucosal layer owing to the buoyancy effect, clear visualization of the bleeding site, and the ability to perform the procedure with lower intraluminal pressure because insufflation is not required.

Preoperative endoscopic appearance of the tumor. A, Conventional duodenoscopy image (forward view). B, Side-viewing duodenoscopy image. A flat elevated tumor located adjacent to the papilla of Vater. C, Inserting a bile duct stent (7F-7 cm, Trough & Pass; Gadelius Medical, Tokyo, Japan) and a pancreatic duct stent (5F-7 cm, Geenen Pancreatic Stent Sets; Cook Japan, Tokyo, Japan) a week before endoscopic treatment.

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