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.

Download video file ^{(70.1MB, mp4)}

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.

Endoscopy_UCTN_Code_TTT_1AO_2AG_3AF

Endoscopy E-Videos https://eref.thieme.de/e-videos .

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 .