Figure 3.

White right endoscopic image, muscular layer surface and longitudinal closure method of the artificial ulcer after resection in case 13 (over-the-scope clip). A: An approximately 20-mm irregularly protruding lesion is observed in the posterior wall side of the slightly anal side of the major duodenal papilla in the descending portion of the duodenum. Duodenal cancer was diagnosed based on the magnifying narrow band imaging results; B: The detached thin myenteric parts could be observed by applying only mild countertraction using the tip hood; C: The largest artificial ulcer floor is approximately 30 mm, occupying half of the circumference of the duodenal lumen. Bile juice directly flowed onto the artificial ulcer floor from the major duodenal papilla (green curved arrow). Reefing closure using an over-the-scope clip (OTSC) was conducted as rapidly as possible while cleaning the ulcer floor. Because closure using the OTSC in the minor axial direction was technically difficult, longitudinal reefing was used; however, no postoperative stenosis was observed (yellow arrows).