Duodenal ESD: conquering difficulties.

Duodenal endoscopic submucosal dissection (ESD) is technically difficult due to the unique anatomic features. The risks include intraprocedural complications, delayed bleeding, and perforation. A small-caliber-tip transparent hood is useful. Mechanical stretching of the submucosal tissue allows safe dissection and effective prevention of bleeding with minimum muscle injury under direct visualization of the submucosal tissue and blood vessels. A short double-balloon endoscope is useful to stabilize control of the endoscope tip in distal duodenal ESD. Selection of ESD in the duodenum should be made cautiously considering both benefits and risks of the procedure.