Clip-and-thread traction-assisted endoscopic submucosal dissection (ESD) is useful for treating GI lesions and offers shortened operative times and a reduced risk of perforation.1, 2, 3, 4 Duodenal ESD is technically challenging; large tumor size and poor endoscopic maneuverability particularly contribute to technical difficulties and intraoperative perforation.5 Herein, we report a technically difficult duodenal ESD that was performed successfully within a short time using multiple clip-and-thread traction. Written informed consent was obtained from the patient after the risks and benefits of the treatment had been fully explained before the dissection.
A 74-year-old man was referred to our institute for treatment of a large, flat-elevated tumor (diameter, 50 mm) in the duodenal bulb (Fig. 1A). Endoscopic examination revealed that the proximal side of the tumor was located just behind the pyloric ring. We selected ESD for the en bloc resection of the lesion, and the patient underwent the procedure under general anesthesia. The procedure was performed using a therapeutic endoscope (GIF-H290T; Olympus Medical Systems Co, Tokyo, Japan).
Figure 1.
A, A large, flat-elevated tumor located in the duodenal bulb (retroflexed view). B, Endoscopic submucosal dissection strategy before traction. 1: Mucosal incision on the proximal side of the tumor (yellow arrows). 2: Submucosal dissection of the posterior wall side of the tumor and creation of a mucosal flap (highlighted in blue). 3: Circumferential mucosal incision is completed (red arrows). C, Three clip-and-threads were deployed to the distal edges of the specimen (each numbered threads with syringes). D, Excellent visualization of the submucosal layer is achieved.
After injecting hyaluronic acid, we made an initial mucosal incision and performed slight submucosal dissection on the proximal side of the tumor in the forward view using a DualKnife J (1.5-mm cutting knife; KD655Q, Olympus). We then performed a submucosal dissection of the tumor’s posterior wall side (ie, on the pylorus side) in the forward view using a Clutch Cutter (3.5-mm knife; DP2618DT-35-; Fujifilm Co, Tokyo, Japan) to create a mucosal flap. Reaching and dissecting the anterior wall side of the tumor in the forward view was unfeasible because of poor endoscope maneuverability. Therefore, we switched to the retroflexed view and made a circumferential incision. A slight submucosal dissection was performed continuously using the DualKnife (Fig. 1B). Subsequently, a clip (HX-610-090; Olympus) and thread (waxed dental floss, Reach; Johnson & Johnson K.K., Tokyo, Japan) were deployed to the center of the tumor’s distal edge for traction. The thread outside the patient’s body was pulled proximally, and submucosal dissection was performed continuously. However, as the tumor was gradually dissected, we discovered that a single point of traction was insufficient for maintaining good visualization of both edges of the submucosal layer at the tumor site. Therefore, 2 additional clip-and-threads were deployed to the right and left distal edges of the specimen, which allowed for safe submucosal dissection with accurate visualization (Fig. 1C and D). We maintained traction by using the syringe weight or by gently pulling each thread proximally. The tumor was completely removed in 65 minutes. The mucosal defect extended nearly two-thirds of the way along the duodenal bulb circumferentially (Fig. 2 and Video 1, available online at www.giejournal.org).
Figure 2.
Mucosal defect without perforation. Forward (A) and retroflexed (B) views.
In duodenal ESD, the risk of delayed perforation is increased owing to exposure of the post-ESD mucosal defect to pancreatic juice and bile acid. Therefore, complete closure of the mucosal defect is crucial in preventing delayed perforation.6 However, in the present case, we anticipated that mucosal defect closure would be difficult because of the large size of the defect and poor maneuverability of the endoscope. Therefore, instead of closing the defect, we decided to conduct a careful observation after tumor resection. Starting from the day of the procedure, proton-pump inhibitors were administered for 2 weeks.
The patient did not develop any adverse events and was discharged on day 6 after ESD. The mucosal defect was completely scarred within 1 month (Fig. 3). Pathologically, the tumor was an intramucosal tubular adenocarcinoma with negative margins and no lymphovascular invasion (Fig. 4).
Figure 3.
The mucosal defect was completely scarred over within 1 month.
Figure 4.
A, Resected specimen with 3 clip-and-threads. B, Resected specimen (60 × 35 mm). C, Pathologically, the tumor is an intramucosal tubular adenocarcinoma with negative margins and no lymphovascular invasion (H&E, orig. mag. ×12.5).
In conclusion, we found that multiple clip-and-thread traction–assisted ESD is suitable for the excision of large tumors in the duodenal bulb; however, further studies are recommended.
Disclosure
All authors disclosed no financial relationships.
Supplementary data
-
•Clip-and-thread traction-assisted ESD has been reported to be useful for treating GI lesions, both for shortening the duration of the procedure and reducing the risk of perforation.
-
●Generally, duodenal ESD is a technically challenging procedure. In particular, large tumor size and poor endoscope maneuverability contribute to technical difficulties and intraoperative perforation.
-
●Here, we report a technically difficult duodenal ESD that was successfully performed with a short procedure time using multiple clip-and-thread traction.
-
●A 74-year-old man was referred to our institute for treatment of a large, flat-elevated tumor, measuring 50 mm in diameter, found in his duodenal bulb.
-
●Endoscopic examination showed that the proximal side of the tumor was located just behind the pyloric ring.
-
●The histologic diagnosis by biopsy of previous hospital was well-differentiated adenocarcinoma. As no lymph node or distant metastasis was observed on abdominal computed tomography, it was diagnosed as early duodenal cancer. Therefore, we selected ESD for en bloc resection of this lesion.
-
●Compared with a tumor in the second portion of the duodenum, a tumor in the duodenal bulb cannot be easily lifted by injection because of the presence of Brunner's glands.
-
●The maneuverability of the endoscope is very poor, and the endoscope easily slips out of the duodenal bulb to the gastric side.
-
●It is difficult to retroflex the endoscope in the duodenal bulb because of the narrow lumen and an increased risk of perforation.
-
●We used a therapeutic endoscope (GIF-H290T). This endoscope has a 9.9-mm outer diameter as well as 210° upward and 120° downward angles.
-
●The left–right range of motion when further curved upward was wider than that of the conventional endoscope (GIF-Q260J), making it an excellent endoscope for approachability in areas such as narrow and bent canals. This endoscope was very useful for locating the tumor in the duodenal bulb in the present case.
-
●We considered the traction technique using a clip-and-thread set to be useful for this tumor.
-
●Because the tumor was large, maintaining traction until the end of submucosal dissection using only a single clip-and-thread would be difficult. Hence, a total of 3 points of clip-and-thread traction were planned.
-
●Because gravity is oriented toward the anterior wall, we planned to create a mucosal flap at the posterior wall of the tumor to allow the endoscope to slide into the submucosal layer.
-
●Endoscopic submucosal dissection strategy before traction: (1) Mucosal incision of the proximal side of the tumor; (2) submucosal dissection of the posterior wall side of the tumor and creation of a mucosal flap; (3) circumferential mucosal incision completed.
-
●In the forward view, the endoscope maneuverability was so poor that it easily slipped out of the duodenal bulb to the gastric side.
-
●After injection of hyaluronic acid, initial mucosal incision and slight submucosal dissection were performed from the proximal side of the tumor using a DualKnife.
-
●Submucosal dissection of the posterior wall of the tumor was conducted on forward view from the pylorus side using a Clutch Cutter to make a mucosal flap.
-
●Subsequently, in the retroflexed view, circumferential mucosal incision and slight submucosal dissection were performed continuously using a DualKnife.
-
●However, the submucosal layer was not sufficiently reflected, and we could not accurately identify the dissection line.
-
●Therefore, for this large tumor, we performed multiple clip-and-thread traction for safe submucosal dissection.
-
●Once the endoscope was withdrawn from the patient, dental floss was tied directly to 1 jaw of the clip.
-
●The endoscope with clip-and-dental floss was reinserted into the patient, in the retroflexed view, and the clip-and-thread was deployed at the center of the distal edge of the specimen.
-
●The thread that was outside the patient's body was gently pulled, and good traction allowed safe Clutch Cutter dissection of the submucosal layer under accurate visual observation.
-
●However, as the tumor was gradually dissected further, this single traction was not sufficient for maintaining good visualization of both edges of the submucosal layer of the tumor site where the clip-and-thread were not applied.
-
●Therefore, an additional 2 points of clip-and-thread traction were deployed at the right and left distal edges of the specimen.
-
●A total of 3 points of clip-and-thread traction were deployed at the distal edge of the specimen, and each thread was numbered first to third.
-
●After deploying multiple points of clip-and-thread traction, first, while gently pulling out the second thread, the submucosal layer of the posterior wall of the tumor was dissected completely by Clutch Cutter under direct visualization.
-
●Subsequently, the second and first threads were pulled further out. By pulling the third thread in conjunction, excellent traction allowed safe and secure dissection of all residual submucosal layer under direct visualization.
-
●Finally, the specimen was drawn into the gastric side by simultaneously pulling all threads to prevent the resected specimen from slipping toward and getting lost in the small bowel. Slight residue of the submucosal layer was then dissected using a DualKnife in the forward view.
-
●The lesion was resected en bloc without any adverse events. The procedure was completed in 65 minutes.
-
●The mucosal defect extended circumferentially to nearly two thirds along the duodenal bulb.
-
●By combining planned multiple clip-and-thread traction, we achieved successful ESD for cases with high technical difficulty and with a short procedure time.
-
●In conclusion, we found that multiple clip-and-thread traction–assisted ESD is suitable for the excision of large tumors in the duodenal bulb; however, further studies are recommended.
References
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- 4.Yamasaki Y., Harada K., Okada H. Traction-assisted endoscopic submucosal dissection for a giant rectal tumor: multiple clip-and-threads technique. Dig Endosc. 2018;30:697–699. doi: 10.1111/den.13204. [DOI] [PubMed] [Google Scholar]
- 5.Kato M., Sasaki M., Mizutani M. Predictors of technical difficulty with duodenal ESD. Endosc Int Open. 2019;7:E1755–E1760. doi: 10.1055/a-0967-4744. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Kato M., Ochiai Y., Fukuhara S. Clinical impact of closure of the mucosal defect after duodenal endoscopic submucosal dissection. Gastrointest Endosc. 2019;89:87–93. doi: 10.1016/j.gie.2018.07.026. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
-
•Clip-and-thread traction-assisted ESD has been reported to be useful for treating GI lesions, both for shortening the duration of the procedure and reducing the risk of perforation.
-
●Generally, duodenal ESD is a technically challenging procedure. In particular, large tumor size and poor endoscope maneuverability contribute to technical difficulties and intraoperative perforation.
-
●Here, we report a technically difficult duodenal ESD that was successfully performed with a short procedure time using multiple clip-and-thread traction.
-
●A 74-year-old man was referred to our institute for treatment of a large, flat-elevated tumor, measuring 50 mm in diameter, found in his duodenal bulb.
-
●Endoscopic examination showed that the proximal side of the tumor was located just behind the pyloric ring.
-
●The histologic diagnosis by biopsy of previous hospital was well-differentiated adenocarcinoma. As no lymph node or distant metastasis was observed on abdominal computed tomography, it was diagnosed as early duodenal cancer. Therefore, we selected ESD for en bloc resection of this lesion.
-
●Compared with a tumor in the second portion of the duodenum, a tumor in the duodenal bulb cannot be easily lifted by injection because of the presence of Brunner's glands.
-
●The maneuverability of the endoscope is very poor, and the endoscope easily slips out of the duodenal bulb to the gastric side.
-
●It is difficult to retroflex the endoscope in the duodenal bulb because of the narrow lumen and an increased risk of perforation.
-
●We used a therapeutic endoscope (GIF-H290T). This endoscope has a 9.9-mm outer diameter as well as 210° upward and 120° downward angles.
-
●The left–right range of motion when further curved upward was wider than that of the conventional endoscope (GIF-Q260J), making it an excellent endoscope for approachability in areas such as narrow and bent canals. This endoscope was very useful for locating the tumor in the duodenal bulb in the present case.
-
●We considered the traction technique using a clip-and-thread set to be useful for this tumor.
-
●Because the tumor was large, maintaining traction until the end of submucosal dissection using only a single clip-and-thread would be difficult. Hence, a total of 3 points of clip-and-thread traction were planned.
-
●Because gravity is oriented toward the anterior wall, we planned to create a mucosal flap at the posterior wall of the tumor to allow the endoscope to slide into the submucosal layer.
-
●Endoscopic submucosal dissection strategy before traction: (1) Mucosal incision of the proximal side of the tumor; (2) submucosal dissection of the posterior wall side of the tumor and creation of a mucosal flap; (3) circumferential mucosal incision completed.
-
●In the forward view, the endoscope maneuverability was so poor that it easily slipped out of the duodenal bulb to the gastric side.
-
●After injection of hyaluronic acid, initial mucosal incision and slight submucosal dissection were performed from the proximal side of the tumor using a DualKnife.
-
●Submucosal dissection of the posterior wall of the tumor was conducted on forward view from the pylorus side using a Clutch Cutter to make a mucosal flap.
-
●Subsequently, in the retroflexed view, circumferential mucosal incision and slight submucosal dissection were performed continuously using a DualKnife.
-
●However, the submucosal layer was not sufficiently reflected, and we could not accurately identify the dissection line.
-
●Therefore, for this large tumor, we performed multiple clip-and-thread traction for safe submucosal dissection.
-
●Once the endoscope was withdrawn from the patient, dental floss was tied directly to 1 jaw of the clip.
-
●The endoscope with clip-and-dental floss was reinserted into the patient, in the retroflexed view, and the clip-and-thread was deployed at the center of the distal edge of the specimen.
-
●The thread that was outside the patient's body was gently pulled, and good traction allowed safe Clutch Cutter dissection of the submucosal layer under accurate visual observation.
-
●However, as the tumor was gradually dissected further, this single traction was not sufficient for maintaining good visualization of both edges of the submucosal layer of the tumor site where the clip-and-thread were not applied.
-
●Therefore, an additional 2 points of clip-and-thread traction were deployed at the right and left distal edges of the specimen.
-
●A total of 3 points of clip-and-thread traction were deployed at the distal edge of the specimen, and each thread was numbered first to third.
-
●After deploying multiple points of clip-and-thread traction, first, while gently pulling out the second thread, the submucosal layer of the posterior wall of the tumor was dissected completely by Clutch Cutter under direct visualization.
-
●Subsequently, the second and first threads were pulled further out. By pulling the third thread in conjunction, excellent traction allowed safe and secure dissection of all residual submucosal layer under direct visualization.
-
●Finally, the specimen was drawn into the gastric side by simultaneously pulling all threads to prevent the resected specimen from slipping toward and getting lost in the small bowel. Slight residue of the submucosal layer was then dissected using a DualKnife in the forward view.
-
●The lesion was resected en bloc without any adverse events. The procedure was completed in 65 minutes.
-
●The mucosal defect extended circumferentially to nearly two thirds along the duodenal bulb.
-
●By combining planned multiple clip-and-thread traction, we achieved successful ESD for cases with high technical difficulty and with a short procedure time.
-
●In conclusion, we found that multiple clip-and-thread traction–assisted ESD is suitable for the excision of large tumors in the duodenal bulb; however, further studies are recommended.