A 57-year-old woman with a history of recurrent duodenal granular laterally spreading
tumor (LST-G) was referred to our hospital. The lesion was located in the second portion
of the duodenum, opposite the papilla. The patient had undergone two endoscopic mucosal
resections (EMRs) in another endoscopy center. Histologic analysis showed a tubular
adenoma with low-grade dysplasia; margins were not evaluable.
Conventional EMR of the recurrent tumor would have been difficult because of submucosal
fibrosis. Endoscopic submucosal dissection (ESD) for duodenal recurrent tumors carries
a high risk of perforation and demands highly advanced skills [1]
[2]. We decided to perform underwater EMR (UEMR), which was described first by Binmoeller
et al. [3] and subsequently demonstrated its usefulness for residual duodenal lesions [4]. The main advantage of this technique is that it avoids submucosal injection and
allows potential resection of fibrotic areas.
The patient consented, and endoscopic procedure was performed under general anesthesia,
orotracheal intubation, in left lateral position. A high-definition gastroscope (EG-590ZW;
Fujinon, Saitama, Japan) was used. We identified an LST-G 40 mm in length in the duodenum,
incorporating three duodenal folds (Pit pattern type III-L) ([Fig. 1]). After making diathermic marks with a multifilament snare (Boston Scientific, Tokyo,
Japan), CO2 insufflation was switched off and exchanged for sterile distilled water. A piecemeal
UEMR was performed using a monofilament snare (Endoflex, Voerde, Germany) and electrosurgical
unit (Endo-cut Q, effect 3, VIO 200; Erbe, Tübingen, Germany). Intraprocedural bleeding
was treated with snare tip soft coagulation (Soft Coagulation 80 W, Effect 4, VIO
200) and coagulation forceps (Boston Scientific, Marlborough, Massachusetts, USA).
Complete resection was achieved in 45 minutes ([Fig. 2], [Video 1]). The postresection defect was not closed with clips. Most of the specimens were
retrieved using a Roth net (US Endoscopy, Mentor, Ohio, USA).
Fig. 1 Endoscopic images. a Duodenal granular laterally spreading tumor. b Chromoendoscopy with indigo carmine showed pit pattern III-L.
Fig. 2 Underwater endoscopic mucosal resection. a Underwater view of the lesion. b Resection with a monofilament snare in a fibrotic area. c Snaring ensured that a wide margin of normal mucosa was captured. d Post-resection defect.
Video 1 Underwater endoscopic mucosal resection of recurrent duodenal lateral spreading tumor.
The patient remained hospitalized, started oral feeding on postoperative Day 1, and
was discharged on Day 2 without adverse events. Histologic analysis revealed a tubular
adenoma with low- and high-grade dysplasia. Upper endoscopy 8 months later showed
no remnant duodenal lesion. Biopsies of the scar revealed no residual adenoma ([Fig. 3]).
Fig. 3 Endoscopic images from follow-up at 8 months. a Duodenal lumen free of remnant lesion. b Yellow arrow shows resection scar. c Histopathologic examination of the scar revealed no adenomatous lesion.
UEMR enables the resection of large laterally spreading duodenal adenomas without
submucosal injection, which is beneficial in fibrotic areas. This case demonstrates
successful endoscopic management of a recurrent duodenal LST, avoiding unnecessary
surgery.
Endoscopy_UCTN_Code_TTT_1AO_2AG
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