Jejunal endoscopic submucosal dissection is feasible using the pocket-creation method and balloon-assisted endoscopy

Endoscopic submucosal dissection (ESD) is widely used for the resection of superficial gastrointestinal neoplasms. Previously, we reported that the pocket-creation method (PCM) overcomes difficulties in ESD, such as in duodenal lesions [1] and subpedunculated neoplastic lesions [2]. Here, we describe the use of the PCM to facilitate ESD of a jejunal lesion.

A 54-year-old woman with familial adenomatous polyposis was referred for resection of a large adenoma in the proximal jejunum. Laparotomy would have been difficult owing to adhesions from previous surgery. Good maneuverability was confirmed in the vicinity of the lesion by double-balloon endoscopy ([Fig. 1]), and we performed ESD using the PCM and balloon-assisted endoscopy (BAE).

Fig. 1 Advantages of balloon-assisted endoscopy (BAE) compared with push enteroscopy. a Push enteroscopy becomes unstable owing to stretching of the gastric and duodenal walls. b By using BAE, the overtube with a balloon prevents a redundant loop, enabling accurate and stable operation without paradoxical movements.

An endoscope with a 3.2-mm working channel (EI-580BT; Fujifilm, Tokyo, Japan) and a small-caliber-tip transparent hood (ST hood; DH-15GR; Fujifilm) were used. The endoscope tip balloon was not attached because the lesion was located in the upper jejunum. The Hook knife (Olympus, Tokyo, Japan) was used for most of the dissection. The key feature of the PCM is entering and dissecting the submucosal layer to make a pocket using an ST hood after a minimal mucosal incision ([Fig. 2]). After creation of the submucosal pocket under the entire tumor, an additional mucosal incision was made and submucosal dissection performed. Use of the PCM for ESD with BAE safely achieved an en bloc resection of the tumor ([Video 1]).

Fig. 2 An endoscopic image and schema of the pocket-creation method of endoscopic submucosal dissection for jejunal neoplastic lesions. a Endoscopic image in a submucosal pocket after creation of the submucosal pocket under the entire tumor. b Schema at the time the pocket was completed.

Video 1 The pocket-creation method for endoscopic submucosal dissection of a jejunal adenoma.

The PCM has four main advantages including: (i) maintaining a thick submucosal layer with a minimal incision; (ii) obtaining good traction by using an ST hood; (iii) conquering the vertical approach by adjusting the direction of the endoscope tip; and (iv) stabilizing the endoscope tip by synchronizing the endoscope and the pocket [1]. By using BAE, the overtube with a balloon prevents formation of a redundant loop, enabling accurate and stable operation without paradoxical movements ([Fig. 1]) [3].

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• References

• 1 Miura Y, Shinozaki S, Hayashi Y. et al. Duodenal endoscopic submucosal dissection is feasible using the pocket-creation method. Endoscopy 2017; 49: 8-14
• 2 Hayashi Y, Sunada K, Takahashi H. et al. Pocket-creation method of endoscopic submucosal dissection to achieve en bloc resection of giant colorectal subpedunculated neoplastic lesions. Endoscopy 2014; 46 (Suppl. 01) E421-E422
• 3 Yamashina T, Hayashi Y, Sakamoto H. et al. Balloon-assisted endoscopy facilitates endoscopic submucosal dissection of difficult superficial proximal colon tumors. Endoscopy 2018; DOI: 10.1055/s-0044-100720.