Endoscopic submucosal dissection for a duodenal polyp at the upper aspect of the duodenal bulb using a newly developed endoscope

Endoscopic examination and resection of a polyp at the upper aspect of the duodenal bulb, especially adjacent to the pylorus, are difficult because of scope maneuverability. After Helicobacter pylori eradication, a 73-year-old woman received a follow-up endoscopy, during which a duodenal polyp at the bulb was identified. A biopsy revealed gastric-type adenoma, and she was subsequently referred to our institute for further examination. The polyp was located at the upper side of the bulb (Fig. 1). The oral side of the tumor was adjacent to the pylorus, but the anal margin could not be identified because of scope maneuverability, as the tumor was located at the upper aspect of the duodenal bulb. Despite using various types of endoscopes, including an ultrathin endoscope (GIF-H290Z, GIF-Q260J, and GIF-XP290N; Olympus, Tokyo, Japan), retroflex observation was impossible because of the narrow space of the bulb and the volume of the polyp itself. Noting no signs of invasion, such as submucosal tumor-like appearance,1Takinami M. Kakushima N. Yoshida M. et al.Endoscopic features of submucosal invasive non-ampullary duodenal carcinomas.J Gastroenterol Hepatol. 2020; 35: 821-826Crossref Scopus (8) Google Scholar we elected to attempt endoscopic resection (Video 1, available online at www.videogie.org). We prepared a newly developed thin endoscope (EG-840TP; Fujifilm, Tokyo, Japan) at 7.9 mm wide with a large working channel of 3.2 mm and wide angles (up 210° and down 160° each). However, retroflex observation at the bulb remained impossible and identifying the anal margin was difficult (Fig. 2). Underwater EMR was considered but dismissed because the polyp could not be snared with its location at the upper aspect of the duodenal bulb. Finally, we attempted endoscopic submucosal dissection (ESD) with the patient under intravenous anesthesia. After injecting hyaluronic acid, mucosal incision began from the oral side (Fig. 3) with the endoscope attached with a hood (DH-083ST; Fujifilm). Using the pulley traction method (Fig. 3),2Oyama T. Counter traction makes endoscopic submucosal dissection easier.Clin Endosc. 2012; 45: 375-378Crossref PubMed Scopus (137) Google Scholar, 3Shichijo S. Matsuno K. Takeuchi Y. et al.Pulley traction-assisted colonic endoscopic submucosal dissection affords good visibility of submucosal layer.VideoGIE. 2018; 3: 358-360Abstract Full Text Full Text PDF PubMed Google Scholar, 4Shichijo S. Takeuchi Y. Matsuno K. et al.Pulley traction-assisted colonic endoscopic submucosal dissection: a retrospective case series.Dig Dis. 2019; 37: 473-477Crossref PubMed Scopus (7) Google Scholar, 5Shichijo S. Takeuchi Y. Waki K. et al.Pulley traction-assisted endoscopic submucosal dissection with hemostatic forceps for a laterally spreading tumor in the ascending colon.VideoGIE. 2020; 5: 684-685Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar we proceeded with submucosal dissection from the oral side. The lesion subsequently repositioned to the anal side, leading to the identification of the anal margin and en bloc resection (Fig. 4). Microperforation occurred (Fig. 5) and was closed after resection (Fig. 6). Levofloxacin was administered to prevent peritonitis. The patient resumed her diet 2 days after ESD, and she was discharged on day 4.Figure 4En bloc resection was achieved.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Microperforation after resection.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Microperforation was closed with a clip.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The final pathologic diagnosis was tubular adenoma, gastric type (immunostaining was focally positive with MUC5AC and positive with MUC6), with negative margins (Fig. 7). A follow-up endoscopy 2 months later confirmed no residual tumor (Fig. 8).Figure 8Narrow-band imaging after 2 months confirmed no residual tumor.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The new endoscope, with its small width at 7.9 mm and wide angles (up 210° and down 160° each) is especially useful for ESD with stricture or for a narrow space like a bulb or pharynx. The authors did not disclose any financial relationships. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIwZjFjMTNkZjM3ODBjN2Q0ODNhMTNhYjIxM2MxYWZjYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk0NTE4NDIxfQ.GIqhGUK3mBnsN8BKI_m8rzRRGH4cvcYIIMihdCRapMB_bG8do4KIrIauWpoq42f2xbCRY3YZtok1e3irLlJ6TOMuynrj14HinGxLsk8DX6GKWfG4ZAPuEUslYU0NkwbMoLc5cf3F4BwwBIBHCXn_3V0wdIGmNSHWhTFZhiGZR0MMzHNG1wOMKTay4h9Gxc-5P41N1njJeg6HakzRoVH74ijiqEpDHFytqo1E5U7-i-mmMVMKjgunHTDJY_5OhwX1hizh1lPh_7SjF-hOASMaecITjDnoMCopI-n-bEOgx-pBqiOEF2sw_GlLSsDAS1_C4vghT9meLemBbHsrCQmHTA Download .mp4 (71.14 MB) Help with .mp4 files Video 1Endoscopic submucosal dissection for a duodenal polyp at the upper aspect of the duodenal bulb using a newly developed endoscope.