UNDERWATER RESECTION OF DUODENAL SUBMUCOSAL TUMOR AND ENDOSCOPIC FULL THICKNESS SUTURING

A 61-year-old man was referred to our institute for subepithelial lesion of the duodenal bulb. Echographic imaging showed a 15-millimeter in diameter, homogeneous, hypoechoic lesion of the fourth layer of the inferior wall of the duodenal bulb. The EUS-guided fine needle aspiration showed a gastrointestinal stromal tumor (GIST). The increasing in size of the GIST with respect to the previous examination indicated resection, which remains the only modality that can offer a permanent cure of GISTs, and avoid tumor rupture and injuries to the pseudocapsule.

Considering the will of the patient and in order to avoid major surgery, a multidisciplinary team (endoscopist, oncologist, and surgeon) proposed an endoscopic mini-invasive approach. The procedure was performed under general anesthesia with administration of prophylactic antibiotics. Dissection was performed using an O-type HybridKnife (Erbe Elektromedizin, Germany) and we just and only inflate saline solution in the lumen in order to prevent retroperitoneal CO2 leak and the consequent subcutaneous emphysema. We performed a full-thickness resection to achieve a radical oncological resection. The excision resulted in a complete duodenal wall defect, about 25 × 25 mm in length, which was closed with tree endosutures placed using OverStitch Endoscopic Suturing System (Apollo Endosurgery, USA). In the post-procedural phase, the patient developed hypochondriac pain easily controlled with single dose of ibuprofen and oral intake was restarted in the fourth post-operative day. In the successively two months follow-up the patient remained asymptomatic.

In conclusion, endoscopic full-thickness resection of duodenal GIST appears to be safe even if skill demanding and can be a valid mini-invasive alternative to surgery.