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

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.

Download Video

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.

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.

Fig. 2 Gel immersion permitted clear visualization, and the lumen could be filled with gel.

Fig. 3 The lesion was successfully and safely captured with an electrocautery snare.

Fig. 4 En bloc resection was performed with a standard snare using a high frequency blended electric cutting current without bleeding and perforation.

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

• References

• 1 Yamasaki Y, Uedo N, Takeuchi Y. et al. Underwater endoscopic mucosal resection for superficial nonampullary duodenal adenomas. Endoscopy 2018; 50: 154-158
• 2 Binmoeller KF, Shah JN, Bhat YM. et al. “Underwater” EMR of sporadic laterally spreading nonampullary duodenal adenomas (with video). Gastrointest Endosc 2013; 78: 496-502
• 3 Uedo N, Nemeth A, Johansson GW. et al. Underwater endoscopic mucosal resection of large colorectal lesions. Endoscopy 2015; 47: 172-174
• 4 Yano T, Nemoto D, Ono K. et al. Gel immersion endoscopy: a novel method to secure the visual field during endoscopy in bleeding patients (with videos). Gastrointest Endosc 2016; 83: 809-811