ESD is an advanced endoscopic procedure that enables therapeutic en bloc resection
of gastrointestinal lesions. Because of the variability in lesion characteristics
and anatomical challenges, each case requires a tailored approach [1].
In recent years, saline immersion therapeutic endoscopy (SITE) has gained prominence
as an effective adjunct in ESD. SITE enhances visibility by eliminating the air-liquid
interface, allowing for precise identification of the submucosal layer, which is critical
for a safe and successful dissection [2]
[3]. The buoyancy effect stabilizes the lesion, reducing the need for additional traction
devices and improving scope maneuverability, thus increasing procedural safety [4]
[5]. Moreover, continuous saline flushing maintains submucosal lift providing a stable
dissection field [3]
[5]. SITE also helps in reducing the gas-related complications.
We present a case of a 65-year-old man discovered to have a laterally spreading tumor,
measuring 40 × 30 mm, at the junction between the second and third parts of the duodenum
([Fig. 1]). Given the thin-walled duodenum, the procedure was challenging. After consultation
with a multidisciplinary team, ESD using the SITE technique was planned. Continuous
saline flushing was performed using the scope’s water pump ([Video 1]). The pocket creation method was employed, starting with a mucosal incision from
the oral side of the lesion to create a short submucosal tunnel, followed by the completion
of the circular incision. SITE facilitated clear delineation of the submucosal structures
(Video Image).
Fig. 1 Duodenal laterally spreading tumor.
Demonstration of endoscopic submucosal dissection of a duodenal laterally spreading
tumor using saline immersion therapeutic endoscopy (SITE).Video 1
En bloc resection was successfully achieved ([Fig. 2]), and after proper inspection of the lesion bed, it was closed with hemoclips ([Fig. 3]). Histopathology confirmed R0 resection of a tubulovillous adenoma with high-grade
dysplasia and clear margins ([Fig. 4], [Fig. 5]). The procedure was performed using an Olympus scope ×1 (1500), a FINEMEDIX knife
(CO,
LTD) with a 1.5 mm tip, and ERBE Vio3 (Endocut I 2,3,2; swift coagulation 2.5) ([Video 1]).
Fig. 2 Retrieved lesion after en bloc resection.
Fig. 3
a Resection bed, b bed closure with hemoclips.
Fig. 4 Gross mapping.
Fig. 5 Histopathology confirms tubulovillous adenoma with high-grade dysplasia. Free lateral
margins (a), free deep margins (b).
Endoscopy_UCTN_Code_TTT_1AO_2AG_3AZ
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
Group A countries and 50% waivers to those who are based in Group B countries as classified
by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
