Underwater endoscopic mucosal resection of residual duodenal tumor

A 51-year-old man underwent screening esophagogastroduodenoscopy (EGD) and was found to have a 15-mm duodenal adenoma opposite the ampulla of Vater. Endoscopic submucosal dissection (ESD) was attempted but was discontinued because of a perforation that was managed by clip closure. He was followed up periodically by EGD and a biopsy taken 2 years later revealed a possible adenocarcinoma. He was therefore referred to our hospital.

EGD revealed a superficial 20-mm elevated lesion ([Fig. 1 a]). Conventional endoscopic mucosal resection (EMR) of the residual tumor with submucosal saline injection would have been difficult because of submucosal fibrosis. Furthermore, ESD for duodenal tumors carries a high risk of perforation [1], and performing ESD on residual lesions demands highly advanced skills. Underwater EMR (UEMR) was developed and described by Binmoeller et al. in 2012 [2]. We previously reported the usefulness of this technique for superficial non-ampullary duodenal adenomas [3]. As for colonic recurrent or residual lesions, UEMR is reportedly effective with a higher en bloc resection rate and lower recurrence rate than conventional EMR [4]. We therefore performed UEMR on this residual duodenal lesion.

Fig. 1 Endoscopic images showing: a a tumor in the duodenum opposite the ampulla of Vater; b the polyp underwater; c the mucosal defect after underwater endoscopic mucosal resection had been performed, with a vessel visible in the defect; d complete closure of the defect using clips.

We used a pediatric colonoscope (EVIS PCF-H290TI; Olympus Medical Systems, Tokyo, Japan) because it is preferable for duodenal lesions owing to its long length and wide down-angle. We evacuated air from the affected segment of lumen and infused water until the lumen was completely full ([Fig. 1 b]), after which we performed hot snare polypectomy without submucosal injection using a Captivator (Boston Scientific, Tokyo, Japan). We resected the lesion en bloc in 4 minutes and completely closed the mucosal defect with clips ([Fig. 1 c, d]; [Video 1]).

Video 1 Underwater endoscopic mucosal resection of residual duodenal tumor.

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The patient commenced oral feeding on day 2 postoperatively and was discharged on day 5. Pathologically, the lesion was an intramucosal adenocarcinoma ([Fig. 2]). Neither endoscopic nor histologic residue was observed at the follow-up EGD 2 months later.

Fig. 2 Photograph of the resected en bloc specimen.

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• References

• 1 Yahagi N, Kato M, Ochiai Y. et al. Outcomes of endoscopic resection for superficial duodenal epithelial neoplasia. Gastrointest Endosc 2018; 88: 676-682
• 2 Binmoeller KF, Weilert F, Shah J. et al. “Underwater” EMR without submucosal injection for large sessile colorectal polyps (with video). Gastrointest Endosc 2012; 75: 1086-1091
• 3 Yamasaki Y, Uedo N, Takeuchi Y. et al. Underwater endoscopic mucosal resection for superficial nonampullary duodenal adenomas. Endoscopy 2018; 50: 154-158
• 4 Kim HG, Thosani N, Banerjee S. et al. Underwater endoscopic mucosal resection for recurrences after previous piecemeal resection of colorectal polyps (with video). Gastrointest Endosc 2014; 80: 1094-1102