Endoscopy 2022; 54(08): E435-E436
DOI: 10.1055/a-1544-7810
E-Videos

Endoscopic mucosal resection under gel immersion for superficial nonampullary duodenal epithelial neoplasms

Tatsuo Yachida
1   Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
2   Department of General Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
,
1   Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
,
Naoya Tada
1   Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
,
1   Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
,
Tadayuki Takata
1   Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
,
Hisashi Masugata
2   Department of General Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
,
Tsutomu Masaki
1   Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
› Author Affiliations

Underwater endoscopic mucosal resection (UEMR) has been recently reported to be effective against superficial nonampullary duodenal epithelial neoplasms (SNADENs) [1]. Superficial lesions float up as protruding lesions under water. This facilitates snaring without submucosal injection and may reduce procedure-associated complications [2] [3]. However, there are some disadvantages to performing UEMR for SNADENs, including difficulty in maintaining a sufficient volume of water owing to anatomical features and gravity.

To overcome these disadvantages, we successfully applied the gel immersion technique, a novel method for securing the endoscopic visual field using gel of an appropriate viscosity (Viscoclear; Otsuka Pharmaceutical Factory, Inc., Tokushima, Japan) [4]. Viscoclear can easily remain in the target region into which it is injected compared with water. We performed successful resection of SNADENs using the gel immersion technique ([Video 1]).

Video 1 Novel method of under-gel endoscopic mucosal resection with gel immersion for superficial nonampullary duodenal epithelial neoplasms.


Quality:

A 60-year-old man had a 12-mm SNADEN (macroscopic type 0-IIa) on the lower surface of the descending duodenum, which we considered an indication for UEMR ([Fig. 1]). However, the lumen could not be filled conventionally with water using a waterjet function (OFP-2; Olympus, Tokyo, Japan). Therefore, we chose the gel immersion technique. First, intraluminal air was removed, and an auxiliary injection cap (BioShield irrigator; US Endoscopy, Ohio, USA) was used for the operative channel. Viscoclear (80 mL) was injected from an irrigation tube using a 50-mL syringe before EMR. Gel immersion permitted clear visualization, enabling quick filling of the lumen ([Fig. 2]). Then, the lesion was successfully and safely captured with an electrocautery snare ([Fig. 3]). En bloc resection was performed without perforation ([Fig. 4]), and the mucosal defect was completely closed using hemoclips ([Fig. 5]). The resected specimen was an adenoma and complete resection was confirmed.

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Fig. 1 The lesion was located on the lower surface of the descending duodenum; the macroscopic type was 0-IIa, and the size was 12 mm.
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Fig. 2 Gel immersion permitted clear visualization, and the lumen could be filled with gel.
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Fig. 3 The lesion was successfully and safely captured with an electrocautery snare.
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Fig. 4 En bloc resection was performed with a standard snare using a high frequency blended electric cutting current without bleeding and perforation.
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Fig. 5 The mucosal defect was completely closed using hemoclips.

EMR under gel immersion may be effective for SNADENs that are difficult to infiltrate conventionally with water.

Endoscopy_UCTN_Code_TTT_1AO_2AG

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Publication History

Article published online:
08 September 2021

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