Wide-field underwater EMR followed by line-assisted complete closure for a large duodenal adenoma.

Duodenal adenoma has a risk of developing into cancer. En bloc resection with conventional EMR is difficult for a large lesion, whereas duodenal endoscopic submucosal dissection is associated with a high risk of perforation. Piecemeal underwater EMR is effective for large duodenal adenomas; however, a large mucosal defect carries a risk of delayed adverse events. Although complete closure after endoscopic resection can reduce adverse events,3, 4 closure of a large mucosal defect with endoclips is difficult. Line-assisted complete closure (LACC) enables complete closure.

A 40-year-old woman with familial adenomatous polyposis presented with a ≥60-mm semicircumferential nongranular-type lateral-spreading tumor (Type 0-IIa in the Paris classification) at the inferior duodenal angle (Figs. 1A and B). Histologic examination of the biopsy specimen revealed mild atypia in the tubular adenoma. The Spigelman score, which indicates the risk of development to duodenal cancer in familial adenomatous polyposis, was 8 (stage III). Narrow-band imaging (NBI), an image-enhancing technology that made it easier to delineate the lesion, was used. The border of the lesion was identified based on differences in the mucosal pattern and color. The mucosal pattern of the lesion was a whitish sulcular pattern with NBI, and the vascular pattern was absent by the white opaque substance. Because downangulation is important to press down the mucosa when the lesion is snared, the procedure was performed with the use of a pediatric videocolonoscope (PCF-Q260JI; Olympus Co, Tokyo, Japan), which has a wide bending range compared with that of an upper-GI endoscope. A transparent hood (D-201-11804; Olympus Co) was attached to the tip of the videocolonoscope for keeping an appropriate distance from the lesion. The procedure was performed with the patient in the left lateral position and under deep sedation using pethidine, midazolam, and dexmedetomidine. After the duodenum was filled with 0.9% saline solution by use of an endoscope-equipped water-jet function, mucosal resection was performed with an electrosurgical snare (Snare Master spiral-type: SD-230U-20; Olympus Co) and electrosurgical unit (Endo-cut Q mode, effect 3, duration 2, and interval 4; VIO300D; Erbe, Tübingen, Germany) under saline solution (Video 1, available online at www.VideoGIE.org; Fig. 2). The tip of the hood was invisible under saline solution because water has a higher refractive index than air, and the endoscopic image was magnified by the optical zoom effect. We observed some minor intraprocedural bleeding, which required endoscopic hemostasis with hemostatic forceps (Coagulasper: FD-410LR; Olympus Co). Complete resection was achieved by performing piecemeal resection 13 times within 29 minutes, and no residual tumor was observed under NBI. A total of 1.5 L of saline solution was used. The mucosal defect was then closed by LACC. A previous report suggested that LACC effectively reduces the incidence of post-ESD coagulation syndrome (PECS). An endoclip (HX-610-090 and HX-110LR; Olympus Co) tied with a nylon line was placed on the normal mucosa at the 5-mm proximal side of the mucosal defect (Fig. 3). Subsequently, the line was anchored to the normal mucosa at the 5-mm distal side with another endoclip. Both sides of the normal mucosa were gathered by pulling the line, and additional endoclips were placed to close the defect completely. After the center of the defect was closed, the line was cut with scissor forceps (FS-3L-1; Olympus Co). A total of 12 clips (1 clip-with-line and 11 clips) were used, and LACC was completed in 23 minutes (Fig. 4). Because the assessment took 8 minutes, the procedure was completed within 60 minutes. Food intake was started on postoperative day 2. The patient was discharged on postoperative day 4 without adverse events. Histopathologic examination of the specimen revealed a low-grade tubular adenoma. Surveillance endoscopy performed in a referring clinic 11 months postoperatively showed no residual tumor, although the interval after piecemeal resection was not as per the international guidelines (Fig. 5).

Figure 1

Endoscopic view of a half-circumferential elevated polyp at the inferior duodenal angle. A, White-light imaging. B, Narrow-band imaging.

Figure 2

Piecemeal underwater EMR performed on the lesion.

Figure 3

Placement of an endoclip tied with a nylon line on the normal mucosa at the proximal side of the defect to close the mucosal defect by a line-assisted complete closure technique.

Figure 4

The line is anchored to the distal side of the defect using another endoclip. The proximal and distal sides of the normal mucosa are gathered by pulling the line, and more endoclips are placed to close the defect completely.

Figure 5

Surveillance endoscopic view 11 months postoperatively in a referring clinic showing no residual tumor.

Disclosure

All authors disclosed no financial relationships relevant to this publication.