LIGATION-ASSISTED ENDOSCOPIC MUCOSAL RESECTION (EBL-EMR) AS A SAFE ALTERNATIVE FOR THE RESECTION OF A FLAT DUODENAL ADENOMA IN A CIRRHOTIC PATIENT WITH ECTOPIC DUODENAL VARICES

Background:

Duodenal lesions not involving the major duodenal papilla can be removed with a variety of EMR techniques, but carries an increased risk of bleeding and perforation because the duodenum has increased vascularity and a thin wall.

Case report:

We present the usage of ligation-assisted EMR for the en-bloc resection of a 15 mm flat duodenal adenoma in a cirrhotic patient with ectopic duodenal varices. A 48-year old woman was reffered to our department for screening EGD regarding her newly diagnosed cirrhosis. Endoscopy revealed except from small esofageal varices, additional ectopic duodenal varices. A flat (Paris classification 0-IIa) duodenal adenoma was also detected opposite the major papilla. Ligation-assisted EMR was chosen for the en-bloc resection due to the efficiency of the method in extruding the muscularis propria layer and entrapping only the mucosa and portions of the submucosa with lower risk of perforation in the thin duodenal wall. Secondly, the ligation band device could guide the operator more accurately in ensnaring with the plastic band the adenomatous polypoid tissue and transform the flat (0-IIa) duodenal polyp to a sessile one (0-Is). The resected specimen was controlled without a target sign. The mucosal defect in the duodenal wall revealed minimal intraprocedural bleeding that was managed with small amount of adenaline diluted into normal saline and sprayed above the bleeding defect. Finally, EMR defect was closed with 3 metallic clips in order to prevent delayed bleeding. The patient discharged the same day without any complications and the final histology report demonstrated tubular duodenal adenoma with low grade dysplasia and clear margins (R0 resection).

Conclusions:

Ligation-assisted EMR could be a safe and accurate method for the removal of flat duodenal adenomas even in cirrhotic patients where the possibility of an acute bleeding is higher and the restoration of a perforation probably more difficult.