We thank Ken Hagiwara and his colleagues for their comments. We agree that the complete a Kocher maneuver is efficient under some circumstances before performing endoscopic submucosal dissection (ESD).
Our standard technique for laparoscopic endoscopic cooperative surgery on duodenal tumors (D-LECS) is to stop the Kocher maneuver before ESD when the anterior wall of the duodenum is well exposed. This helps to prevent a difficult ESD due to loss of duodenal fixation on the retroperitoneum. Additional exfoliation of the posterior wall of the duodenum is done, when necessary, after ESD.
In their letter, the authors suggest changing the endoscopic view by complete Kocher maneuver before ESD to make the technique easier when it is difficult to obtain a stable view with a partial Kocher maneuver or no such maneuver. We agree that their technique would be useful in some duodenal tumors, such as tumors located at the superior or inferior duodenal angles, locations in which ESD is technically difficult to perform.
The optimal timing of completing the Kocher maneuver differs among cases of D-LECS. We recommend stopping the Kocher maneuver before ESD and checking whether ESD is feasible. Whenever ESD is not technically feasible, a Kocher maneuver should be completed before ESD.
Footnotes
Competing interests The authors declare that they have no conflict of interest.