Endoscopic submucosal dissection using countertraction with clips and rubber band allows safe en bloc resection of recurrent duodenal superficial lesions with intense fibrosis

Superficial duodenal epithelial neoplasia ([Fig. 1]) can be endoscopically removed either with cold snare resection, conventional endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). EMR is safe but can lead to a 20 % – 30 % recurrence rate because of piecemeal resections. Conversely, duodenal ESD has a high rate of en bloc resection but is technically challenging and has ≤ 50 % risk of complications (bleeding and perforation) [1] [2].

Fig. 1 Duodenal adenomatous polyps. a Narrow-band imaging (NBI). b Dual-focus NBI.

We present the case of a 60-year-old patient with multiple sporadic duodenal adenomas. One of the lesions was particularly challenging because it was a recurrence after a previous EMR. Hybrid endoscopic resection was attempted but impossible due to severe submucosal fibrosis. We therefore performed ESD using the clip and rubber band traction technique ([Video 1]) [3] [4]. We closed the duodenal scar using clips and the patient was discharged after 48 hours of follow-up. The histology exam showed en bloc resection of a low-grade dysplastic duodenal adenoma and there were no complications after 3 weeks of follow-up.

Video 1 Endoscopic submucosal dissection using countertraction for recurrent duodenal superficial lesions.

This is one of the first video cases showing ESD for duodenal recurrent lesions with severe fibrosis. As a full-thickness resection device for resection of upper digestive tract lesions is not yet approved in Europe, ESD using countertraction techniques can be an option for cases with intense fibrosis and high risk of perforation using conventional EMR.

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Publication History

Article published online:
17 April 2020

• References

• 1 Yahagi N, Kato M, Ocihai Y. et al. Outcomes of endoscopic resection for superficial duodenal epithelial neoplasia. Gastrointest Endosc 2018; 88: 676-682
• 2 Kato M, Sasaki M, Mizutani M. et al. Predictors of technical difficulty with duodenal ESD. Endosc Int Open 2019; 07: E1755-E1760
• 3 Jacques J, Charissoux A, Bordillon P. et al. High proficiency of colonic endoscopic submucosal dissection in Europe thanks to countertraction strategy using a double clip and rubber band. Endosc Int Open 2019; 9: E1166-E1174
• 4 Faller J, Jacques J, Oung B. et al. Endoscopic submucosal dissection with double clip and rubber band traction for residual or locally recurrent colonic lesions after previous endoscopic mucosal re-section. Endoscopy 2020;