Duodenal endoscopic submucosal dissection with a retracted needle knife

Endoscopic submucosal dissection (ESD) of the duodenum is technically challenging, with a high risk of intraoperative perforation and delayed adverse events [1]. Valuable methods, such as the water pressure [2] and traction-assisted methods [3] have been reported. The DualKnife retracts with 0.1 mm left outside the sheath ([Fig. 1]). This feature is useful for marking and hemostasis [4]. There is a risk of perforation when the submucosal layer is dissected using a knife facing the muscle layer. We report that safe and effective dissection was possible with the retracted DualKnife and traction assistance.

A 71-year-old man presented with a 20-mm type 0-IIc duodenal adenocarcinoma in the second portion of the duodenum ([Fig. 2]). ESD was performed using a therapeutic endoscope (GIF-H290T; Olympus, Tokyo, Japan) and 1.5-mm DualKnife J (KD-655L; Olympus) under general anesthesia ([Video 1]). A short, small-caliber-tip transparent hood (DH-28GR; Fujifilm, Tokyo, Japan) was used. Mucosal incision was made using the underwater and conventional methods. Dissection was performed underwater, with the water pressure method as appropriate. After the full-circumference incision and flap were made, traction toward the opposite side was created with a multi-loop traction device (Boston Scientific, Marlborough, Massachusetts, United States). When the knife faced the muscle layer or the scope was unstable, the submucosa was dissected with a retracted knife ([Fig. 3]). The submucosa can be effectively dissected with a light touch of the retracted knife under proper traction. The risk of intraoperative perforation is reduced because the knife does not penetrate the muscle layer. However, there is a risk of muscle layer coagulation if the knife is pressed hard against the submucosa. En bloc resection was achieved without perforation ([Fig. 4]), and the ulcer was closed entirely with clips to prevent delayed perforation. We demonstrated a safe duodenal ESD with a retracted needle knife.

Fig. 1 Comparison of the tip of the DualKnife J in extended and retracted conditions. When the tip of the knife is retracted, 0.1 mm of the tip remains outside the sheath (arrow).

Fig. 2 White light image of the lesion. A 20-mm type 0-IIc duodenal cancer was located at the second portion of the duodenum. The pathological analysis confirmed well-differentiated tubular adenocarcinoma, pTis, Ly0, V0, HM0, VM0.

Fig. 3 A single coagulation with a retracted knife is sufficient to dissect. a The retracted knife is set in the field of view facing the muscle layer. b After each coagulation with the retracted knife, adequate submucosal dissection is performed (arrows) without muscle layer damage.

Fig. 4 En bloc resection is achieved without perforation.

Duodenal endoscopic submucosal dissection with a retracted needle knife.Video 1

Publication History

Received: 18 January 2023

Accepted after revision: 07 June 2023

Article published online:
01 August 2023

• References

• 1 Kato M, Takeuchi Y, Hoteya S. et al. Outcomes of endoscopic resection for superficial duodenal tumors: 10 years' experience in 18 Japanese high volume centers. Endoscopy 2022; 54: 663-670 DOI: 10.1055/a-1640-3236. (PMID: 34496422)
• 2 Kato M, Takatori Y, Sasaki M. et al. Water pressure method for duodenal endoscopic submucosal dissection (with video). Gastrointest Endosc 2021; 93: 942-949
• 3 Tashima T, Jinushi R, Ishii N. et al. Effectiveness of clip-and-thread traction-assisted duodenal endoscopic submucosal dissection: a propensity score-matched study (with video). Gastrointest Endosc 2022; 95: 918-928
• 4 Yahagi N, Uraoka T, Ida Y. et al. Endoscopic submucosal dissection using the Flex and the Dual knives. Tech Gastrointest Endosc 2011; 13: 74-78