Novel endoscopic approach for safe and effective resection of duodenal neuroendocrine tumor

A 76-year-old woman presented with a 10-mm duodenal neuroendocrine tumor (d-NET) located in the duodenal bulb and confined to the submucosa ([Fig. 1] a). Conventional endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) carries high risks of perforation and of obscuring the vertical margin. We have devised a method ([Video 1]) to provide an equivalent treatment option in facilities where the full-thickness resection and closure device is unavailable.

Fig. 1 Cap-assisted endoscopic mucosal resection of a duodenal neuroendocrine tumor (d-NET) with an over-the-scope (OTS) clip. a The 10-mm d-NET. b Confirmation that the lesion could be suctioned into the distal cap attachment. c An OTS clip is deployed directly beneath the lesion, resulting in a pseudopolypoid elevation. d, e The lesion is resected by cap-assisted endoscopic mucosal resection with the OTS clip effectively preventing perforation. f Endoscopic full-thickness resection is achieved.

Novel cap-assisted endoscopic mucosal resection of a duodenal neuroendocrine tumor (d-NET) with an over-the-scope (OTS) clip.Video 1

Initially, a GIF-XZ1200 endoscope (Olympus, Tokyo, Japan) equipped with a distal cap attachment was employed to confirm that the lesion could be suctioned into such an attachment ([Fig. 1] b). The endoscope was then switched to a GIF-2TQ260M (Olympus), fitted with an over-the-scope (OTS) clip system (10 mm; Ovesco Endoscopy); the clip was deployed directly beneath the lesion, resulting in a pseudopolypoid elevation of the lesion ([Fig. 1] c). The endoscope was switched back to the GIF-XZ1200 with a distal attachment (MAJ-290, Olympus) and a snare (SD-221-L25) was positioned ([Fig. 1] d). The elevated lesion was resected under full suction into the attachment. Endoscopic full-thickness resection was achieved, with the OTS clip effectively preventing perforation ([Fig. 1] e, f). Histopathological examination confirmed an 8-mm NET (grade 1) limited to the submucosal layer, with negative margins, and without lymphovascular invasion ([Fig. 2] a, b).

Fig. 2 a Resected specimen. b Hematoxylin–eosin staining (low magnification).

In Japan, where the full-thickness resection device is not available, the EMR with OTS clip technique, termed EMRO, offers a promising method for treating d-NETs [1]. However, certain cases may pose challenges, particularly in those of snare resection. In the present case, using full suction with a transparent cap fitted over the OTS clip facilitated successful snaring, demonstrating the simplicity and reliability of this technique. This EMROC method is less costly than using the full-thickness resection device for lesions less than 10 mm, while effectively providing full-thickness resection for d-NETs.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• Reference

• 1 Tashima T, Ryozawa S, Tanisaka Y. et al. Endoscopic resection using an over-the-scope clip for duodenal neuroendocrine tumors. Endosc Int Open 2021; 9: E659-E666

Publication History

Article published online:
08 November 2024