Endoscopic submucosal dissection (ESD) is standard for early gastric cancer (EGC); however, pyloroduodenal lesions remain technically challenging due to complex anatomy. Despite reported traction-assisted ESD techniques for these sites, experience with truly circumferential pyloric lesions remains limited. 1 2 3 We present a case of complete circumferential pyloric EGC successfully resected en bloc using a dual-tunnel approach.
A 52-year-old woman presented with a circumferential, slightly elevated white lesion involving the pylorus and extending into the duodenal bulb, where it was clearly visualized upon retroflexion using a GIF-290 endoscope ( Fig. 1a, b ). Magnifying endoscopy revealed irregular microvessels and microsurface patterns on the gastric side, while on the duodenal side, elongated crypt openings were observed with white opaque substance (WOS) deposition ( Fig. 1c, d ). Inspired by the dual-tunnel technique for esophageal circumferential lesions, we applied it here to overcome the anatomical constraints ( Video 1 ). First, a circumferential mucosal incision was made on the duodenal side under retroflexed ( Fig. 2a ). Second, markings and mucosal incisions were performed on the gastric side ( Fig. 2b ). Third, an entry point was created along the greater curvature, and the first submucosal tunnel was dissected from the antrum toward the bulb ( Fig. 2c, d ), revealing the pyloric circular muscle (yellow arrow) and Brunner's glands (red arrow). Fourth, with traction suture assistance, a second tunnel was established along the lesser curvature ( Fig. 2e, f ).
Fig. 1.
The manifestations of the lesion under white light and magnifying endoscopy. ( a and b ) The circumferential, slightly elevated white lesion involving the pylorus and extending into the duodenal bulb, where it was clearly visualized upon retroflexion using a GIF-290 endoscope. ( c and d ) The microvessels and microsurface structures on the gastric side were irregular, the crypt openings were elongated, and WOS deposits were present on the duodenal side.
Fig. 2.
A double-tunnel ESD approach was performed for the circumferential gastric cancer. ( a and b ) Circumferential mucosal incisions were made on the duodenal and gastric side of the lesion. ( c and d ) The first submucosal tunnel was constructed from the gastric antrum toward the duodenal bulb. ( e and f ) With rubber band-assisted traction, create the second submucosal tunnel along the lesser curvature side of the lesion.
Video 1 Dual-tunnel endoscopic submucosal dissection for circumferential early gastric cancer involving the pylorus and duodenal bulb. Video URI: .
The post-dissection defect is shown; no perforation occurred ( Fig. 3a ). Histology of the 7.5×5 cm resection specimen confirmed well-differentiated tubular adenocarcinoma, classified as eCura A ( Fig. 3b ). To prevent stenosis, oral prednisolone (30 mg/d, tapered by 5 mg biweekly over 12 wk) was combined with a self-control water balloon placed on postoperative day 3. The balloon was retained for 12 weeks with regular volume adjustments, eliminating the need for repeat dilation 4 ( Fig. 3c ). At the 5-month follow-up after the operation, the pylorus remained unobstructed, and no signs of stenosis or local recurrence were observed ( Fig. 3d ).
Fig. 3.
Post-ESD wound and measures to prevent stenosis. ( a ) The post-dissection defect is shown. ( b ) The resected specimen measured 7.5 × 5 cm. ( c ) The self-control water balloon. ( d ) The pylorus remained unobstructed after a 5-month follow-up period.
To our knowledge, this is the first reported en bloc ESD for a truly circumferential EGC involving the pylorus and duodenal bulb, highlighting the potential of advanced endoscopic techniques in anatomically challenging areas.
Endoscopy_UCTN_Code_TTT_1AO_2AG_3AD
Declaration of GenAI Use
The authors used WorkBuddy (artificial intelligence [AI] writing assistant) for language polishing and grammar refinement of this manuscript. All AI-assisted contents were carefully reviewed and revised by the authors, who take full responsibility for the final content.
Footnotes
Conflict of Interest The authors declare that they have no conflict of interest.
Contributorsʼ Statement Cheng Guo: data curation and writing – original draft. Zeyu Wang: formal analysis. Jingze Li: project administration and validation. Meidong Xu: writing – review and editing.
References
- 1.Mori H, Yamamoto Y, Niida K et al. Endoscopic resection of gastric cancer involving pylorus and duodenum using novel anchor ring-shaped thread counter traction. Endoscopy. 2025;57:E811–E812. doi: 10.1055/a-2641-2253. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Tashima T, Jinushi R, Ishii N et al. Effectiveness of clip-and-thread traction-assisted duodenal endoscopic submucosal dissection: a propensity score-matched study (with video) Gastrointest Endosc. 2022;95:918–928. doi: 10.1016/j.gie.2021.12.024. [DOI] [PubMed] [Google Scholar]
- 3.Tashima T, Miyaguchi K, Tanisaka Y et al. Successful duodenal endoscopic submucosal dissection using multiple clip-and-thread traction for a large tumor located in the duodenal bulb. VideoGIE. 2021;6:178–180. doi: 10.1016/j.vgie.2020.12.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Lian J, Chu Y, Chen T et al. Outcome of a novel self-control stricture-preventing water balloon for complete circular esophageal endoscopic submucosal dissection. Surg Endosc. 2023;37:290–297. doi: 10.1007/s00464-022-09456-8. [DOI] [PubMed] [Google Scholar]