Duodenal Endoscopic Submucosal Dissection Research Articles

Upper gastrointestinal endoscopic submucosal dissection using an ultrathin endoscope: a retrospective, single-center evaluation.

Recent studies have reported the therapeutic use of endoscopic submucosal dissection (ESD) using an ultrathin endoscope for targeting pharyngeal and distal side lesions in the stenosis or as a less invasive treatment via the nasal route. However, the effectiveness and safety of these treatments remain undetermined. Therefore, this study aimed to review treatment outcomes and discuss the advantages and precautions of the treatments based on our experience. This study included 13 patients with 14 lesions who underwent 14 sessions of upper gastrointestinal ESD using an ultrathin endoscope between December 2021 and August 2023. The outcome measures included lesion background, en bloc resection rate, en bloc complete resection rates, and incidence of adverse events (including post-operative bleeding, intraoperative perforation, and delayed perforation). The lesions in the esophagus, stomach, and duodenum were eight, three, and three, respectively, and the median length (range) of each located lesion was 16.5 (6-26), 17 (9-36), and 10 (4-16) mm, respectively. En bloc resection and en bloc complete resection rates were 100 and 92.9%, respectively. The only adverse event was an intraoperative perforation observed during duodenal ESD, resulting from the assistant's inadvertent expansion of the SOUTEN at the final dissection stage. Our results demonstrate that ESD with an ultrathin endoscope effectively reaches lesions in difficult locations and enables treatment within a small working space. Therefore, ESD using an ultrathin endoscope is a treatment option for lesions located distally to gastrointestinal stenosis, highly fibrotic lesions, and duodenal tumors.

Novel clip closure technique for a large mucosal defect with anchor-pronged clips after duodenal endoscopic submucosal dissection.

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The role of endoscopic submucosal dissection in the treatment of large superficial duodenal epithelial neoplasia

Background and Aims: Endoscopic submucosal dissection is one of the recommended treatment modality in terms of facilitating en-bloc resection in patients with superficial duodenal epithelial neoplasm larger than 2 cm. There is limited information in the literature about the applicability of endoscopic submucosal dissection in superficial duodenal epithelial neoplasm. In this single-center study, the results of eight patients with superficial duodenal epithelial neoplasm who underwent endoscopic submucosal dissection were retrospectively analyzed. Materials and Methods: Twelve patients who underwent duodenal endoscopic submucosal dissection between February 2019 and November 2023 were screened. Eight patients with superficial duodenal epithelial neoplasm larger than 2 cm were included in the study. Results: The median tumor diameter was 27.5 mm (20 - 80 mm). The most common localization was the duodenum second part (87.5%). En bloc and R0 resection rates were each 100%. The median procedure time was 37.5 min. Two patients (20%) with complications were treated with endoscopic clips. No recurrence was observed in all patients (mean 21 months). Conclusion: Endoscopic submucosal dissection is a technically challenging but successful method in the treatment of superficial duodenal epithelial neoplasm. Due to the high risk of complications, duodenal endoscopic submucosal dissection should be performed in experienced centers.

Safety of Duodenal Endoscopic Submucosal Dissection for Superficial Non-Ampullary Duodenal Epithelial Tumor: A Single-Center Study in the United States.

Endoscopic submucosal dissection (ESD) of superficial non-ampullary duodenal epithelial tumors (SNADETs) is associated with a high rate of en bloc resection and low rate of recurrence. However, in the United States, SNADETs are predominantly managed using endoscopic mucosal resection (EMR) or surgery because the feasibility and safety of duodenal ESD have not yet been established. In this study, we analyzed the outcomes of duodenal ESD for SNADETs. This single-center retrospective study reviewed the data of patients who underwent ESD for SNADETs between June 2018 and August 2023. Baseline patient characteristics, histopathology of the resected lesions, adverse events, and recurrence rates were evaluated. The primary outcome measures were en bloc resection, complications, and recurrence rate. Thirty ESD procedures were performed on 24 patients. All 30 lesions were adenomas, with no cancerous lesions. The en bloc resection rate and R0 resection rates were both 53%. There were no cases of procedure-associated perforation. Post-ESD bleeding was observed in six cases. No ESD-related mortality was observed. The recurrence rate was 14% in 1 year follow up, and 28% the during all follow-up period. ESD is a safe option for SNADET in the United States; however further comparative studies are necessary to determine the optimal procedure for North American populations.

Duodenal endoscopic submucosal dissection with a retracted needle knife.

Duodenal endoscopic submucosal dissection with a retracted needle knife.

Effective and Secure Closure after Duodenal Endoscopic Submucosal Dissection: Combination of Endoscopic Ligation with O-Ring Closure and Over-the-Scope Clip

Duodenal endoscopic submucosal dissection (ESD) is associated with high incidences of intraoperative complications and delayed adverse events (AEs). Delayed AEs can be reduced by closing the post-ESD defects. We developed a new method of closure after duodenal ESD, combining endoscopic ligation with O-ring closure (E-LOC) with an over-the-scope clip (OTSC) (Band OTSC; B-OTSC). Here, we conducted a single-center, retrospective, observational study to investigate the efficacy and safety of the B-OTSC method for preventing delayed AEs in patients undergoing duodenal ESD. The study included nine patients with superficial nonpapillary duodenal epithelial tumors who underwent ESD and were closed with B-OTSC from February 2021 to February 2023. There were no delayed AEs (0%), the mean (± standard deviation) closure time was 53 ± 21.6 min, the complete closure rate was 100%, and the mean hospital stay was 7.8 ± 1.8 days. The sustained closure rates at postoperative days 3 and 7 were 88.9% and 88.9%, respectively. The historical analysis indicated a significant difference in cost between B-OTSC and conventional OTSC (p < 0.01). In conclusion, B-OTSC was a safe, secure, and cost-effective method of closure after duodenal ESD, even in patients with post-ESD defects of more than half the circumference.

Usefulness of the S-O clip for duodenal endoscopic submucosal dissection: a propensity score-matched study.

Endoscopic submucosal dissection (ESD) for superficial non-ampullary duodenal tumors (SNADETs) is associated with a high rate of en bloc resection. However, the technique for ESD remains challenging. Recent studies have demonstrated the effectiveness of S-O clips in colonic and gastric ESD. We evaluated the efficacy and safety of duodenal ESD using an S-O clip for SNADETs. Consecutive patients who underwent ESD for SNADETs between January 2011 and December 2021 were retrospectively enrolled. Propensity score matching analysis was used to compare patients who underwent duodenal ESD with the S-O clip (S-O group) and those who underwent conventional ESD (control group). Intraoperative perforation rate was the primary outcome, while procedure time and R0 resection rate were the secondary outcomes. After propensity score matching, 16 pairs were created: 43 and 17 in the S-O and control groups, respectively. The intraoperative perforation rate in the S-O group was significantly lower than that in the control group (p=0.033). A significant difference was observed in the procedure time between the S-O and control groups (39±9 vs. 82±30 minutes, respectively; p=0.003). The S-O clip reduced the intraoperative perforation rate and procedure time, which may be useful and effective in duodenal ESD.

Application of a new loop cutter for nylon lines and the reopenable clip-over-line method for large defect closure after duodenal endoscopic submucosal dissection.

Application of a new loop cutter for nylon lines and the reopenable clip-over-line method for large defect closure after duodenal endoscopic submucosal dissection.

A "clip-thread-elastic ring" internal traction device for endoscopic submucosal dissection of a duodenal tumor.

Duodenal endoscopic submucosal dissection (ESD) is one of the most challenging procedures. We developed a “clip–thread–elastic ring” internal traction device to facilitate ESD procedures in the duodenum ([Fig. 1]). The device consists of an endoscopic clip, a surgical thread, and an elastic ring cut with scissors from a commonly used sterile glove. Herein, we report the application of this device to facilitate an ESD procedure in a 52-year-old man with a flat tumor in the descending duodenum ([Fig. 2 a]; [Video 1]).

Underwater clipping in the colon.

Clipping closure of large mucosal defects in the gastrointestinal tract can be difficult and time consuming, and sometimes requires many clips as the mucosa surrounding the defect stretches following endoscopic mucosal resection (EMR). Techniques utilizing the underwater method have been increasingly used in various endoscopic procedures [1] [2] [3]. Its application in clipping has been reported in large colonic and duodenal endoscopic submucosal dissection [4]. Here, we demonstrate the use of underwater clipping after EMR in the colon ([Video 1]).

Conventional Clips vs Over-the-Scope Clips for Mucosal Defects Closure After Duodenal Endoscopic Submucosal Dissection

Conventional Clips vs Over-the-Scope Clips for Mucosal Defects Closure After Duodenal Endoscopic Submucosal Dissection

Effects of Sprayable, Highly Adhesive Hydrophobized Gelatin Microparticles on Endoscopic Submucosal Dissection: A Swine Model

Introduction: Sprayable wound dressings containing hydrophobized microparticles (hMPs) are characterized by strong adhesiveness. We examined the effect of hMPs derived from Alaska pollock gelatin on endoscopic submucosal dissection (ESD) ulcers. Methods: (1) In an in vivo model of miniature swine gastric ESD, gastric ulcers were created by ESD and then sprayed with hMPs or untreated followed by microscopic examination. (2) In an ex vivo ESD model of resected stomach, a pinhole-shaped perforation was created on the ESD ulcer of resected stomach; hMPs were then sprayed on the perforation; and air leakage and intragastric pressure were measured. (3) In an in vivo duodenal ESD model of miniature swine, duodenal artificial ESD ulcers with pinhole-shaped perforation were examined; ulcers were classified into hMPs-sprayed and nonsprayed groups, and inflammation in the intrinsic muscle layer and serosa were compared between the groups. Results: (1) Histological observation of submucosal tissues showed a decreased number of invading inflammatory cells in hMP-sprayed tissues compared with the control in miniature swine gastric ESD (p < 0.05). In addition, the rates of anti-alpha smooth muscle actin and type I collagen positivity were significantly lower in the hMPs group than in the control group (p < 0.05). (2) Intragastric pressure could not be measured in the nonsprayed group, whereas no air leakage was observed in the sprayed group when pressurized up to 26 mm Hg in the resected stomach model. (3) The sprayed group showed suppressed inflammation of the intrinsic muscular layer and serosa in both cases compared with the nonsprayed group in miniature swine duodenal ESD (p < 0.05). Conclusions: Sprayable, tissue-adhesive hMPs are a promising medical material for intraoperative and postoperative treatment of ESD-induced wound via anti-inflammation and strong adhesiveness.

Endoscopic submucosal dissection with reinforcement using a laparoscopic approach for a duodenal cavernous hemangioma.

Video 1Endoscopic submucosal dissection with reinforcement using a laparoscopic approach (duodenal-laparoscopic and endoscopic coordinated surgery with endoscopic submucosal dissection) for a duodenal cavernous hemangioma. The mucosal defect was reinforced with laparoscopic seromuscular sutures after duodenal endoscopic submucosal dissection was performed.

Closure of large mucosal defects for prevention of strictures after duodenal endoscopic submucosal dissection (with video)

Although lesions occupying a large circumference are associated with the risk of post-endoscopic submucosal dissection (ESD) strictures, the corresponding data for duodenal lesions are unknown. We aimed to analyze the incidence of post-ESD strictures after wide-field duodenal ESD. In this retrospective study of duodenal lesions treated with ESD between July 2010 and August 2021, we included lesions that resulted in mucosal defects occupying more than half of the circumference and excluded lesions located in bulbs and involving Vater's papilla. We analyzed the incidence rates of stricture and luminal narrowing, in addition to bleeding and perforation as the outcomes in this study. Stricture was defined as the inability of the endoscope to pass through the lumen. A single endoscopist reviewed all endoscopic images and judged the degree of luminal narrowing. Eighty lesions were included, of which 2 involved mucosal defects occupying more than 90% of the circumference. The wound was closed, at least partially, in 90% in all lesions and in 86% of lesions with a mucosal defect occupying more than 75% of the circumference. None of the lesions caused delayed perforation and stricture, whereas 2 lesions caused delayed bleeding. Only 6 lesions caused luminal narrowing. When examined by the degree of closure, the rate of luminal narrowing increased with complete closure, incomplete closure, and nonclosure (4.9%, 9.1%, and 25.0%, respectively). Suturing may prevent post-ESD bleeding and perforation as well as stricture formation in cases of duodenal tumors, with mucosal defects occupying a large circumference.

S1107 Duodenal Endoscopic Submucosal Dissection in the United States: A Single Center Case Series

Introduction: Endoscopic Submucosal Dissection (ESD) is a well-established effective endoscopic technique which facilitates en bloc removal of gastrointestinal epithelial lesions. Duodenal ESD is a relatively novel and rare procedure in the United States (US). Here we report a single-center case series of duodenal ESD in the US. Methods: Patients who received ESD at Memorial Sloan Kettering Cancer Center from June 2018 to May 2022 were reviewed (n=477) and a total of 29 patients who had duodenal ESD were included in this study. Gender, age, American Society of Anesthesiology (ASA) score, type of sedation, type of solution for submucosal lifting agents, procedure time, location of the lesion, en bloc resection rate, R0 (complete) resection rate, presence of scar, adverse events, final pathology, and the length of hospital stay were reviewed. Results: A total of 29 patients had duodenal ESD (6.0%). 13 were female (44.8%), 16 were male (55.2%) and the median age was 68 (range 40 – 79). 25 cases (86.2%) had adenoma, 3 cases (10.3%) had neuroendocrine tumor and 1 had no tumor in the final pathology report. 23 were performed under general anesthesia (79.3%) and 6 with propofol sedation (20.7%). 10 patients (34.5%) were classified ASA Ⅱ and 19 patients (65.5%) were ASA Ⅲ. The location of lesions was 2nd part (15/29, 51.7%), followed by 3rd part (10/29, 34.5%), 1st part and bulb (3/29, 10.3%). En bloc resection was achieved in 14 cases (48.3%) and 3 had post-endoscopic mucosal resection (EMR)/ polypectomy scars (3/14, 21.4%). R0 resection rate was 44.8% (13 cases). Of 15 of piecemeal resections (51.7%), 4 had post-EMR/ polypectomy scars (4/15, 26.7%). En bloc and piecemeal resection rate were not affected by the presence of scars (p=0.35). ORISE was used in 16 cases (55.2%) and Eleview was used in 13 cases (44.8%) as the lifting solution and en bloc resection rate was 50% (8/16) with ORISE cases and 46.2% (6/13) in Eleview cases. Mean procedure time was 119 minutes (range 24 -240). As a complication, no perforations were noted. 1 patient developed post-ESD pancreatitis after the removal of large adenoma involving ampulla. The median length of hospital stay was 2 days (range 0 - 20). (Table) Conclusion: This study demonstrated that the duodenal ESD is safe and feasible in the US. The current task is to increase more skilled endoscopists for ESD procedures. Further studies with a larger population are necessary to investigate safety and efficacy in the US. Table 1. - The Data of Duodenal Endoscopic Submucosal Dissection (ESD), Single-Center Case Series Rate of en bloc or piecemeal resection were not affected by the presence of scars (p=0.35) n % Duodenal ESD cases total 29 Gender Female 13 44.8 Male 16 55.2 Age Median age 68 Sedation type General anesthesia 23 79.3 Propofol sedation 6 20.7 ASA score ASA II 10 34.5 ASA III 19 65.5 Location of the lesions 1st part, bulb 3 10.3 2nd part 15 51.7 2nd and 3rd part 1 3.4 3rd part 10 34.5 En bloc (n) % Lifting solution Eleview 13 44.8 6 46.2 ORISE 16 55.2 8 50 Post-EMR/polypectomy scars Scar positive (n) % Resection type En bloc 14 48.3 3 21.4 Piecemeal 15 51.7 4 26.7 Procedure time Mean time 119min Median time 110min Adverse events after ESD Post-ESD pancreatitis 1 3.4 Final pathology Adenoma 25 86.2 NET 3 10.3 No tumor 1 3.4 R0 resection 13 44.8 Maximum size of resected area Mean of maximum size 28.2mm Length of hospital stay Mean length 2.48days Median length 2days ESD: Endoscopic submucosal dissection ASA: American Society of Anesthesiology EMR: Endoscopic mucosal resection NET: Neuroendocrine tumor

Novel traction and mucosal defect closure methods using clip-traction bands for duodenal endoscopic submucosal dissection.

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Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: Literature review over one decade.

Endoscopic submucosal dissection (ESD), which enables curative en bloc resection of early gastrointestinal neoplasms, has been an attractive minimally invasive surgery during the past two decades. Large post-ESD defects must be carefully managed to prevent adverse events (AEs). The major AEs comprise delayed bleeding (DB) and delayed perforation (DP), and overall AEs comprise DB plus DP. This review aimed to clarify the clinical efficacy and technical outcomes of endoscopic prophylactic closure for post-ESD defects. We identified studies involving ≥10 patients up to March 2022 in which endoscopic closure was applied for gastric, duodenal, and colorectal post-ESD defects. In the stomach, total rates of overall AEs and DB were significantly lower in the closure than non-closure group. In the duodenum, total rates of overall AEs, DB, and DP were significantly lower in the closure group. In the colorectum, total rates of overall AEs and DB were significantly lower in the closure group. Closure techniques, categorized into three groups (clip-based techniques, mechanical clipping, and surgical stitch-based techniques), were illustrated. Endoscopic closure demonstrated a certain ability to reduce DB after gastric, duodenal, and colorectal ESD as well as DP after duodenal ESD. Considering closure-associated costs, the indications and limitations of closure techniques should be further investigated.

Clinical Efficacy of Endoscopic Submucosal Dissection for the Treatment of Duodenal Lesions in Terms of Operative Technique and Management of Complications.

Background and Aims: Duodenal endoscopic submucosal dissection (ESD) has been considered to be the most challenging because of its high incidence of complications, which has hindered the development of duodenal ESD. The aim of this study is to discuss operation tips for duodenal ESD and to assess the efficacy and safety of duodenal ESD. Patients and Methods: Eighty-two patients who underwent ESD in the digestive endoscope center for superficial duodenal epithelial tumors (SDETs) from January 2017 to June 2021 were studied. Patients were divided into three groups according to the occurrence of complications, and the clinical characteristics and surgical efficacy of each group were compared. Results: SDETs in 82 patients were completely removed by ESD, with a 97.5% R0 resection rate. The average size of resected lesions was 23.8 ± 6.5 mm. There were significant differences in lesion size and operation time between the normal and intraprocedural complication groups (P < .05). Similarly, between the normal and delayed complication groups, significant differences were noted in lesion location, size, operation time, occupied circumference, and postoperative hospitalization duration (P < .05). Conclusion: Duodenal ESD is prone to complications that increase the complexity of the procedure. By improving the necessary technique and skills, duodenal ESD remains safe and effective.

Effectiveness and safety of endoscopic submucosal dissection using the pocket creation method in the Japanese population: a systematic review and meta-analysis.

Background and study aims Endoscopic submucosal dissection (ESD) is a standard method for minimally invasive resection of superficial gastrointestinal tumors. The pocket creation method (PCM) facilitates ESD regardless of location in the gastrointestinal tract. The aim of this systematic review and meta-analysis is to evaluate the effectiveness and safety of ESD for superficial neoplasms in the upper and lower gastrointestinal tract comparing the PCM to the non-PCM. Methods Randomized controlled, prospective, and retrospective studies comparing the PCM with the non-PCM were included. Outcomes included en bloc resection, R0 resection, dissection speed, delayed bleeding and perforation. Pooled odds ratios (ORs) with 95 % confidence intervals (CIs) using the Mantel-Haenszel random effect model were documented. Results Eight studies including gastric, duodenal, and colorectal ESD were included. The en bloc resection rate was significantly higher in the PCM group than the non-PCM group (OR 3.87, 95 %CI 1.24–12.10 P = 0.020). The R0 resection rate was significantly higher in the PCM group than the non-PCM group (OR 2.46, 95 %CI 1.14–5.30, P = 0.020). The dissection speed was significantly faster in the PCM group than the non-PCM group (mean difference 3.13, 95 % CI 1.35–4.91, P < 0.001). The rate of delayed bleeding was similar in the two groups (OR 1.13, 95 %CI 0.60–2.15, P = 0.700). The rate of perforation was significantly lower in the PCM group than the non-PCM group (OR 0.34, 95 %CI 0.15–0.76, P = 0.009). Conclusions The PCM facilitates high-quality, fast and safe colorectal ESD. Further studies are needed regarding the utility of PCM in ESD of the upper gastrointestinal tract.

A specimen collection technique to ensure that the resected specimen is safely retrieved after duodenal ESD.

Video 1Collection technique for the resected specimen after duodenal endoscopic submucosal dissection using endo-devices. Large grasping forceps were used in Case 1, and a collecting net was used in Case2.