Post written by Chen-Shuan Chung, MD, MSc, from the Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.

In this case, we described a modified endoscopic submucosal dissection (ESD) method for management of a fibrotic duodenal neoplasm.

A 77-year-old woman presented with a 2.5-cm 0-IIa lesion on a surgical scar at the anterior wall of the duodenal bulb. ESD was performed with a gastroscope (EG-760Z; Fujifilm, Tokyo, Japan) equipped with a small-caliber-tip (8-mm inner diameter) transparent hood (ST Hood, DH-28 GR; FujiFilm), a DualKnifeJ (Olympus Medical Systems, Tokyo, Japan), and glycerol solution mixed with indigo carmine for submucosal dissection and injection.

The mucosal incision was made initially on the anal side of the lesion before incision of the oral side. Severe fibrotic changes with difficulty in lifting the submucosa were noticed during dissection.

Therefore, we performed saline pressure method ESD using the waterjet function of the gastroscope connected to an irrigation pump (EIP2; Erbe, Tübingen, Germany). The duodenum was continuously filled with the saline solution. Under the saline immersion pressure, we could visualize the submucosal layer broadly, helping us identify the dissection plane more clearly. The previous surgical suture lines were noted in the muscle layer underneath the lesion.

Finally, the duodenal wall defect was closed with endoclips (SureClip; Micro-Tech Corporation, Nanjing, China) without immediate adverse events, and the procedure time was 68 minutes. Pathology reported a sessile serrated lesion with focal low-grade dysplasia, and the horizontal and vertical resection margins were free of the neoplasm. The patient was hospitalized for 3 days as planned.

Endoscopic resection of a fibrotic neoplasm is challenging with the conventional ESD method. The buoyancy of the lesion and loosening tissue above the muscle layer under saline immersion make dissection of a fibrotic neoplasm easier and safer. Unnecessary invasive surgery could be avoided with the modified ESD method with organ preservation. 

In conclusion, water pressure method ESD is very useful in endoscopic management of fibrotic duodenal neoplasms.

A, Severe fibrotic changes, with (B) difficulty in lifting the submucosa during dissection, were noted. C, Using the saline pressure method to widen the submucosa layer and identify the incision edges.

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