Gel immersion endoscopic mucosal resection of a duodenal adenoma with gastric phenotype

Endoscopic mucosal resection (EMR) is the most common endoscopic intervention for duodenal neoplasms. The literature describes various options, including cold snare polypectomy, underwater EMR (UEMR), and endoscopic submucosal dissection (ESD) [1] [2]. The gel immersion EMR method has been developed in recent years to achieve safe and easy en bloc resection [3] [4]. Here, we report the en bloc resection of an elevated lesion with a prominent depression in the duodenal bulb using the gel immersion EMR technique.

An elderly man (age >80 years) was found to have a 20-mm elevated lesion in the duodenal bulb ([Fig. 1]). Biopsy of this revealed a duodenal adenoma with gastric phenotype. With the use of narrow-band imaging (NBI) magnification, granular mucosal micropatterns of varying sizes were observed ([Fig. 2]). Endoscopic ultrasound (EUS) revealed that the duodenal muscularis propria maintained a circular shape and was not aligned with the fold involutions ([Fig. 3]). We performed gel immersion EMR ([Video 1]). The lesion was resected en bloc after securely entrapping the normal mucosa surrounding the lesion within the 15-mm snare [5] ([Fig. 4] a). No perforation or any other muscular layer damage was observed, and the EMR ulcer was closed with clips. Pathologic findings confirmed a 17×14-mm duodenal adenoma with gastric phenotype, with negative margins ([Fig. 4] b).

Fig. 1 White-light endoscopic image showing a 20-mm elevated lesion with a prominent depression in the center at the duodenal bulb.

Fig. 2 Narrow-band imaging magnification image of the lesion, which was diagnosed as being a duodenal adenoma with gastric phenotype.

Fig. 3 Endoscopic ultrasound image showing that the duodenal muscularis propria was preserved in a circular shape and was not adhering to the involutions of the folds.

Gel immersion endoscopic mucosal resection is performed for a duodenal adenoma; visualization of the lesion was improved with the use of Viscoclear.Video 1

Fig. 4 The resected specimen: a on macroscopic view, showing the lesion was resected completely en bloc; b on histopathologic microscopic view, showing a 17×14-mm duodenal adenoma with gastric phenotype, with negative margins.

Gel immersion EMR has been associated with a higher R0 resection rate than UEMR [3]. Similarly to UEMR, the duodenal muscularis propria is not pulled to the lesion side when water is stored and it is therefore considered a safe treatment. Likewise, in this case, EUS was used to confirm the course of the duodenal muscularis propria, and gel immersion EMR was performed. A local injection may not obtain a protuberance in the center of a lesion that has a prominent depression, such as in this case. Gel immersion EMR may therefore be useful for such lesions.

Endoscopy_UCTN_Code_TTT_1AO_2AG_3AC

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 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
• 2 Hoteya S, Yahagi N, Iizuka T. et al. Endoscopic submucosal dissection for nonampullary large superficial adenocarcinoma/adenoma of the duodenum: feasibility and long-term outcomes. Endosc Int Open 2013; 1: 2-7
• 3 Miyakawa A, Kuwai T, Sakuma Y. et al. A feasibility study comparing gel immersion endoscopic resection and underwater endoscopic mucosal resection for superficial nonampullary duodenal epithelial tumors. Endoscopy 2023; 55: 261-266
• 4 Yamashina T, Shimatani M, Takahashi Y. et al. Gel immersion endoscopic mucosal resection (EMR) for superficial nonampullary duodenal epithelial tumors may reduce procedure time compared with underwater EMR (with Video). Gastroenterol Res Pract 2022; 2022: 2040792
• 5 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

Publication History

Article published online:
05 June 2024