Endoscopy 2018; 50(09): 931-932
DOI: 10.1055/a-0626-6893
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© Georg Thieme Verlag KG Stuttgart · New York

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

Mizuho Iida
1  Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
,
Hirotsugu Sakamoto
1  Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
,
Yoshimasa Miura
1  Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
,
Tomonori Yano
1  Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
,
Yoshikazu Hayashi
1  Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
,
Alan Kawarai Lefor
2  Department of Surgery, Jichi Medical University, Shimotsuke, Japan
,
Hironori Yamamoto
1  Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
› Author Affiliations
Further Information

Corresponding author

Hironori Yamamoto, MD, PhD
3311-1 Yakushiji
Shimotsuke
Tochigi 329-0498
Japan   
Fax: +81-285-406598   

Publication History

Publication Date:
28 June 2018 (eFirst)

 

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).

Zoom Image
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]).

Zoom Image
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.

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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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Competing interests

Hironori Yamamoto has patents for ESD devices and double-balloon endoscopy produced by Fujifilm Corporation. He also has a consultant relationship with the Fujifilm Corporation and has received honoraria, grants, and royalties from the company. Yoshimasa Miura, Tomonori Yano, and Yoshikazu Hayashi have received honoraria from Fujifilm Corporation.


Corresponding author

Hironori Yamamoto, MD, PhD
3311-1 Yakushiji
Shimotsuke
Tochigi 329-0498
Japan   
Fax: +81-285-406598   


Zoom Image
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.
Zoom Image
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.