Duodenal endoscopic submucosal dissection (ESD) is a challenging procedure for large
tumors involving the papilla [1]. We previously reported a dual-channel rapid hemostasis (RH) technique using a gas-free
immersion (GFI) system that effectively stopped bleeding during gastric ESD with saline
immersion [2]
[3]. This method involves performing ESD using a double-channel endoscope (GIF-2TQ260M;
Olympus), with hemostatic forceps pre-inserted into one of the accessory channels.
Here, we present a case of a large duodenal tumor involving the papilla, in which
ESD was performed using this method.
The patient had a 50-mm duodenal tumor in the papilla. En bloc resection was performed
using saline-immersion ESD with RH and the GFI system ([Fig. 1], [Video 1]). First, a calibrated, small-caliber tip, transparent hood (CAST hood; TOP, Tokyo,
Japan) with a 4-mm tapered tip was attached to the scope [4]. Hemostatic forceps were preinserted into one of the accessory channels. After insertion
of the scope, a hyaluronic acid solution was locally injected into the submucosal
layer, and a mucosal incision was made at a distance from the tumor. The papilla was
intentionally preserved, and an incision was made directly above the muscle layer
to separate the bile and pancreatic ducts. A large blood vessel was observed on the
anal side of the papilla and was pre-sealed with hemostatic forceps. When active bleeding
occurred during submucosal dissection, hemostasis was easily achieved by bringing
the hemostatic forceps close to the bleeding point and closing them. Flow-assisted
coagulation using GFI enabled non-contact hemostasis under saline immersion by positioning
the forceps near the bleeding point and coagulating the tissue. Using these techniques,
the tumor was resected in 43 minutes. The remaining mucosal defect measured 60 mm;
therefore, endoscopic biliary and pancreatic drainage tubes were inserted, and the
defect was completely closed using the reopenable clip over the line method [5].
Fig. 1 Endoscopic submucosal dissection (ESD) of a large duodenal tumor involving the papilla
using dual-channel rapid hemostasis and the gas-free immersion (GFI) system. a Duodenal tumor including the papilla, measuring 50 mm. b Submucosal dissection using the GFI system with a calibrated, small-caliber tip,
transparent hood (CAST hood) featuring a 4 mm a tapered tip, enabling dissection without
visual interruption from bubbles. c, d In case of bleeding, rapid hemostasis can be achieved by compressing the bleeding
site with the broad surface of the CAST hood. e, f Bleeding from thick blood vessels is stopped using flow-assisted coagulation with
the GFI system, achieving hemostasis across an area matching the inner diameter of
the CAST hood. g The bile and pancreatic ducts were separated just above the muscle layer, allowing
direct visualization of both openings. h A 60 mm mucosal defect following complete resection, including the papilla. i Complete closure of the mucosal defects using the reopenable clip over the line method,
with endoscopic biliary and pancreatic drainage tubes inserted without embedding.
Duodenal ESD of a large tumor involving the papilla using dual-channel rapid hemostasis
and the gas-free immersion system.Video 1
Endoscopy_UCTN_Code_TTT_1AO_2AG_3AD
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