Efficacy and safety of endoscopic submucosal dissection using a scissors-type knife with prophylactic over-the-scope clip closure for superficial non-ampullary duodenal epithelial tumors

Endoscopic hemostasis with a self-assembling peptide gel during endoscopic submucosal dissection and cold-snare polypectomy in the duodenum: Prospective exploratory study (with video)

OBJECTIVES

A novel self-assembling peptide gel (SAPG) was recently developed for hemostasis during endoscopic resection (ER) as an alternative for electrocoagulation and clip placement. Therefore, this exploratory study aimed to evaluate the hemostatic effect of SAPG on bleeding during ER of the duodenum.

METHODS

Patients with superficial duodenal epithelial tumors who underwent endoscopic submucosal dissection (ESD) or cold-snare polypectomy (CSP) between June 2022 and October 2023 were enrolled in the study. SAPG was used for hemostasis of the intraprocedural bleeding when spontaneous hemostasis was essential for the continuation of ESD or was not achieved within 30 s after CSP. The primary outcome was a successful hemostatic rate using SAPG.

RESULTS

Among the included patients, 15 and 8 underwent ESD and CSP, respectively. Forty-two points of intraoperative bleeding were noted during ESD, of which 39 (92.9%) and 3 (7.1%) were oozing and nonspurting bleedings, respectively. Successful hemostatic rates were 84.6% and 0% in the oozing and nonspurting bleedings, respectively. All nonspurting bleedings were weakened after SAPG use. Of the 70 CSPs, 60 were oozing bleedings (85.7%), which were successfully stopped with SAPG. The median time to hemostasis from SAPG application was 30 s (interquartile range [IQR] 17-40 s) and 25 s (IQR 10-33 s) during ESD and CSP, respectively. No adverse event was observed in any of the cases during the perioperative period.

CONCLUSION

Self-assembling peptide gel has an acceptable effect of successful hemostasis for intraoperative oozing bleeding during duodenal ESD and CSP.

Feasibility of modified double-layered suturing for a large mucosal defect after duodenal endoscopic submucosal dissection (origami method)

A modified double-layered suturing procedure (origami method; OGM) can achieve robust closure, even for large mucosal defects, by folding the muscle layer using through-the-scope clips. This study aimed to evaluate the feasibility of OGM in duodenal endoscopic submucosal dissection (ESD).This retrospective, observational study was conducted at a tertiary care hospital. We reviewed cases of OGM attempted after duodenal ESD between June 2022 and April 2023. We excluded lesions located in the duodenal bulb or involving the major papilla. We measured the clinical characteristics and outcomes.OGM was attempted in 28 cases after duodenal ESD. The median mucosal defect size was 38 mm (range 26-110). Complete closure was achieved in 27 cases (96%), including the largest lesion. The median closure time was 16 minutes. There were no perforations caused by clips. Delayed perforation and bleeding were not observed. Among 28 cases, 21 underwent follow-up endoscopy 3-5 days after ESD, and the muscle layer remained folded in all cases.OGM achieved a high rate of complete closure even after duodenal ESD. Closure with OGM was robust enough to maintain the folded muscle layer for at least 3 days postoperatively.

A novel reopenable clip with sharp claw for complete closure of mucosal defects after colorectal endoscopic submucosal dissection

The MANTIS Closure Device (MCD; Boston Scientific, Marlborough, Massachusetts, USA) is a reopenable clip with a sharp claw used for closure after endoscopic submucosal dissection (ESD). We evaluated the effectiveness of the MCD for fast and complete closure after colorectal ESD.Cases involving closure with the MCD after ESD of 20-60-mm colorectal lesions between April 2023 and January 2024 were reviewed. The primary end point was complete closure of the ESD defect with the MCD. Secondary end points included closure time, delayed bleeding, delayed perforation, and post-ESD coagulation syndrome (PECS). MCD application involved: 1) grasping the mucosa on the anal-side of the defect; 2) pushing the clip toward the oral-side mucosa and deploying it; 3) adding other reopenable clips for complete closure.61 cases involving MCD were analyzed. Mean tumor size was 32.3 (SD 9.2) mm. Complete closure rate was 98.4% and mean closure time was 6.9 (SD 2.6) minutes. The mean number of MCDs and other clips used was 1.0 (SD 0.1) and 4.7 (SD 1.4), respectively. Rates of delayed bleeding, delayed perforation, and PECS were 0%, 0%, and 9.8%, respectively.Fast and complete closure after colorectal ESD was successfully achieved using the MCD.

Short-term outcome of endoscopic submucosal dissection using a clutch cutter for subepithelial lesions within the esophagogastric submucosa: a Japanese prospective observational study

BACKGROUND/AIMS

The efficacy and safety of endoscopic submucosal dissection using a clutch cutter (ESD-CC) for subepithelial lesions within the esophagogastric submucosa (SELEGSM) has not been investigated. This study aimed to assess the efficacy and safety of ESD-CC for the treatment of SELEGSM.

METHODS

This prospective study included 15 consecutive patients with 18 SELEGSMs diagnosed by endoscopic ultrasonography. The primary outcomes were short-term outcomes including en bloc resection rate, R0 resection rate, procedure time, and complication rate. The secondary outcome was final histological diagnosis.

RESULTS

Among the participants, 18 lesions were identified: 12 in the stomach (nine patients) and six in the esophagus (six patients). The en bloc resection rate was 94.4% (17/18). The R0 resection rate was 88.9% (16/18). The median operating time was 39 min, and no instances of perforation or bleeding were observed. The final diagnoses of SELEGSM included six neuroendocrine tumors (33.3%), six granular cell tumors (33.3%), two ectopic pancreases (11.1%), one inflammatory fibroid polyp (5.6%), one leiomyoma (5.6%), one lipoma (5.6%), and one leiomyosarcoma (5.6%).

CONCLUSIONS

ESD-CC appears to be a technically efficient and safe approach for SELEGSM resection, suggesting its potential as a valuable treatment option.

A method of "Noninjecting Resection using Bipolar Soft coagulation mode; NIRBS" for superficial non-ampullary duodenal epithelial tumor: a pilot study

BACKGROUND

Complete endoscopic resection of superficial non-ampullary duodenal epithelial tumors (SNADETs) is technically difficult, especially with an extremely high risk of adverse event (AE), although various endoscopic resection methods including endoscopic mucosal resection (EMR), underwater EMR (UEMR), and endoscopic submucosal dissection (ESD) have been tried for SNADETs. Accordingly, a novel simple resection method that can completely resect tumors with a low risk of AEs should be developed.

AIMS

A resection method of Noninjecting Resection using Bipolar Soft coagulation mode (NIRBS) which has been reported to be effective and safe for colorectal lesions is adapted for SNADETs. In this study we evaluated its effectiveness, safety, and simplicity for SNADETs measuring ≤ 20 mm.

RESULTS

This study included 13 patients with resected lesions with a mean size of 7.8 (range: 3-15) mm. The pathological distributions of the lesions were as follows: adenomas, 77% (n = 10) and benign and non-adenomatous lesions, 23% (n = 3). The en bloc and R0 resection rate was 100% (n = 13). The median procedure duration was 68 s (32-105). None of the patients presented with major AEs including bleeding and perforation.

CONCLUSIONS

Large studies such as prospective, randomized, and controlled trials should be conducted for the purpose of validating effectiveness, safety, and simplicity of the NIRBS for SNADETs measuring ≤ 20 mm suggested in this study.

Application of balloon occluder for specimen collection after descending duodenal ESD

Endoscopic submucosal dissection (ESD) is a popular technique for resecting duodenal tumors. However, there is a risk of losing resected specimens during the procedure, particularly for lesions in the descending part of the duodenum. This study aims to introduce a simple and effective method for specimen collection after descending duodenal ESD using a self-made balloon occluder. The balloon occluder, made from a spray pipe and sterile rubber glove, is utilized to prevent the loss of resected specimens. The balloon is inflated under endoscopic visualization, occluding the descending lumen. With careful timing, the resected specimen can be safely collected by grasping it from the balloon using foreign forceps. This method has been successfully applied in several cases, demonstrating its practicality and efficacy. Further evaluation and validation of this technique in a larger patient population are warranted to establish its wider application in clinical practice.

Multiple duodenal epithelial tumors in a patient with polymerase proofreading-associated polyposis in POLE variant

Polymerase proofreading-associated polyposis (PPAP) is a rare disease with autosomal-dominant inheritance caused by germline variants in the POLE and POLD1 genes. PPAP has been reported to increase the risk of multiple cancers, including colon, duodenal, and endometrial cancers. Herein, we report a case in which multiple duodenal tumors led to the detection of a POLE mutation. A 43-year-old woman underwent esophagogastroduodenoscopy (EGD). Multiple duodenal tumors were detected, and all lesions were treated endoscopically. The patient had a history of multiple colorectal cancers and endometrial cancer along with a family history of cancer; hence, genetic testing was performed, and POLE variant, c.1270C > G (p.Leu424Val) was detected. Hereditary colorectal cancer syndromes should be considered in patients with colorectal cancer who have multiple cancers or a family history of cancer, and multigene panel sequencing is useful in confirming the diagnosis. In addition, duodenal tumors frequently coexist in patients with PPAP-carrying POLE variants, while the endoscopic treatment for duodenal tumors becomes safe and useful with several new approaches. Therefore, surveillance EGD is necessary in such patients for the early detection and treatment of duodenal tumors.

Short- and long-term outcomes of endoscopic submucosal dissection and laparoscopic and endoscopic cooperative surgery for superficial non-ampullary duodenal epithelial tumors

BACKGROUND AND AIMS

This retrospective study aimed to compare the short- and long-term outcomes of endoscopic submucosal dissection and laparoscopic and endoscopic cooperative surgery in patients with superficial non-ampullary duodenal epithelial tumors.

PATIENTS AND METHODS

We investigated consecutive patients with SNADETs > 10 mm in size who underwent ESD (ESD group) or LECS (LECS group) between January 2015 and March 2021. The data was used to analyze the clinical course, management, survival status, and recurrence between the two groups.

RESULTS

A total of 113 patients (100 and 13 in the ESD and LECS groups, respectively) were investigated. The rates of en bloc resection and curative resection were 100% vs. 100% and 93.0% vs. 77.0% in the ESD and LECS groups, respectively, with no significant difference. The ESD group had shorter resection and suturing times than the LECS group, but there were no significant difference after propensity score matching. There were also no differences in the rates of postoperative adverse event (7.0% vs. 23.1%; P = 0.161). The 3-year overall survival (OS) rate was high in both the ESD and LECS groups (97.6% vs. 100%; P = 0.334). One patient in the ESD group experienced recurrence due to liver metastasis; however, no deaths related to SNADETs were observed.

CONCLUSION

ESD and LECS are both acceptable treatments for SNADETs in terms of a high OS rate and a low long-term recurrence rate, thereby achieving a comparable high rate of curative resection. Further studies are necessary to compare the outcomes of ESD and LECS for SNADETs once both techniques are developed further.

Clinical outcomes of the over-the-scope clip closure after duodenal endoscopic submucosal dissection: A multicenter retrospective study

BACKGROUND AND AIM

Prophylactic closure with the over-the-scope clip (OTSC) after endoscopic submucosal dissection (ESD) of superficial non-ampullary duodenal epithelial tumors (SNADETs) has been reported to reduce postoperative adverse events (AEs). However, there are few evidences regarding AEs-associated factors and long-term outcomes of OTSCs.

METHODS

From January 2011 to December 2020, 139 consecutive patients with SNADETs who underwent ESD followed by OTSC closure in five institutions were extracted in this retrospective study. The primary endpoint was the rate of postoperative AEs after prophylactic OTSC closure. The secondary endpoints were the complete closure rate, residual rate, and long-term AEs associated with residual OTSCs.

RESULTS

The rate of complete closure of the mucosal defect was 97.3% (142) in 146 SNADETs, which were completely resected by ESD. Postoperative AEs, including delayed bleeding, delayed perforation, and localized peritonitis, occurred in 6.2%, 3.4%, and 2.1% of patients, respectively; however, all of the cases improved without surgical treatment. In the multivariate logistic regression analysis, the use of two or more OTSCs was a significant independent risk factor for postoperative AEs (odds ratio, 2.94; 95% confidence interval, 1.02-8.46; P = 0.046). The residual OTSC rate was 46.4% at 1 year postoperatively, and long-term AEs included duodenal erosions and ulcers associated with residual OTSCs.

CONCLUSIONS

Prophylactic closure with OTSCs after duodenal ESD can provide acceptable short-and long-term outcomes for preventing postoperative AEs. However, multiple OTSCs were the independent risk factors of postoperative AEs due to the gaps between and near the OTSCs.

Underwater clip closure method for mucosal defects after duodenal endoscopic submucosal dissection (with video)

Conventional clip closure of mucosal defects after duodenal endoscopic submucosal dissection decreases the incidence of delayed adverse events, but may result in incomplete closure, depending on size or location. This study aimed to assess the effectiveness of the underwater clip closure method for complete duodenal defect closure without the difficulties associated with conventional closure methods. We investigated 19 patients with 20 lesions who underwent endoscopic submucosal dissection of the duodenum and subsequent mucosal defect closure in underwater conditions at our facility between February 2021 and January 2022. The success rate of the underwater clip closure method was defined as the complete endoscopic closure of the mucosal defect; a success rate of 100% was achieved. The median resected specimen size was 34.3 mm, the median procedure time for mucosal defect closure was 14 min, and the median number of clips used per patient was 12. No delayed adverse events were observed. The underwater clip closure method is a feasible option for complete closure of mucosal defects, regardless of the size or location of a duodenal endoscopic submucosal dissection.

Clinical course and management of adverse events after endoscopic resection of superficial duodenal epithelial tumors: Multicenter retrospective study

OBJECTIVES

This study aimed to elucidate the clinical course and management of adverse events (AEs) after endoscopic resection (ER) for superficial duodenal epithelial tumors (SDETs).

METHODS

Consecutive patients who underwent ER of SDETs between January 2008 and July 2018 at 18 Japanese institutions were retrospectively enrolled. The study outcomes included the clinical course, management, and risk of surgical conversion with perioperative AEs after ER for SDETs.

RESULTS

Of the 226 patients with AEs, the surgical conversion rate was 8.0% (18/226), including 3.7% (4/108), 1.0% (1/99), and 50.0% (12/24) of patients with intraoperative perforation, delayed bleeding, or delayed perforation, respectively. In the multivariate logistic analysis, involvement of the major papilla (odds ratio [OR] 12.788; 95% confidence interval [CI] 2.098-77.961, P = 0.006) and delayed perforation (OR 37.054; 95% CI 10.219-134.366, P < 0.001) were significant risk factors for surgical conversion after AEs. Delayed bleeding occurred from postoperative days 1-14 or more, whereas delayed perforation occurred within 3 days in all cases.

CONCLUSIONS

The surgical conversion rate was higher for delayed perforation than those for other AEs after ER of SDETs. Involvement of the major papilla and delayed perforation were significant risk factors for surgical conversion following AEs. In addition, reliable prevention of delayed perforation is required for 3 days after duodenal ER to prevent the need for surgical interventions.

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

BACKGROUND/AIMS

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.

METHODS

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.

RESULTS

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).

CONCLUSION

The S-O clip reduced the intraoperative perforation rate and procedure time, which may be useful and effective in duodenal ESD.

Endoscopic diagnosis and treatment of superficial non-ampullary duodenal epithelial tumors: A review

The surface of the small bowel mucosa is covered more than any other section of the digestive canal; however, the overall prevalence of small bowel tumors of the whole gastrointestinal tract is evidently low. Owing to the improvement in endoscopic techniques, the prevalence of small bowel tumors has increased across multiple countries, which is mainly due to an increase in duodenal tumors. Superficial non-ampullary duodenal epithelial tumors (SNADETs) are defined as tumors originating from the non-ampullary region in the duodenum that share similarities and discrepancies with their gastric and colorectal counterparts in the pathogenesis and clinicopathologic characteristics. To date, white light endoscopy (WLE) remains the cornerstone of endoscopic diagnosis for SNADETs. Besides, narrow-band imaging (NBI) techniques and magnifying endoscopy (ME) have been widely used in the clinic and endorsed by multiple guidelines and consensuses for SNADETs' evaluation. Confocal laser endomicroscopy (CLE), endocytoscopy (ECS), and artificial intelligence (AI) are also up-and-coming methods, showing an exceptional value in the diagnosis of SNADETs. Similar to the endoscopic treatment for colorectal polyps, the choices for SNADETs mainly include cold snare polypectomy (CSP), endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and laparoscopic endoscopic cooperative surgery (LECS). However, owing to the narrow lumen, rich vascularity, weak muscle layer, abundant Brunner's gland, and the hardship of endoscope control, the duodenum ranks as one of the most dangerous operating areas in the digestive tract. Therefore, endoscopists must anticipate the difficulties in endoscopic maneuverability, remain aware of the increased risk of complications, and then select the appropriate treatment according to the advantages and disadvantages of each method.

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

Background and Aims

Over-the-scope clips (OTSCs) are used for treating gastrointestinal perforations, postoperative anastomotic leakages, and mucosal defect closure after endoscopic resections. However, OTSCs are expensive and associated with fatal complications; therefore, proper OTSC usage is necessary. Criteria of OTSC use for mucosal defect closure after duodenal endoscopic submucosal dissection (ESD) are scarce. We examined closure outcomes with OTSCs and conventional clips in patients undergoing duodenal ESD, analyzed the resected specimen area, estimated the preoperative size of tumors treated with each method, and attempted to clarify the criteria for the use of OTSCs vs conventional clips.

Methods

Endoscopic resection was performed for 133 superficial duodenal epithelial tumors from April 2017 to February 2022. Complete closure of mucosal defects after duodenal ESD was attempted for 82 superficial non-ampullary duodenal epithelial tumors, divided into OTSC and control (conventional clips used) groups. Closure outcomes were analyzed.

Results

The overall rate of complete mucosal defect closure in both groups was 98.8%. Significant between-group differences existed in the median estimated tumor size and median resected specimen area.

Conclusion

Conventional clips work well for mucosal defects ≤18 mm after duodenal ESD, but for those >18 mm, a combination of OTSCs may be considered.

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.

Efficacy of endoscopic over-the-scope clip fixation for preventing migration of self-expandable metal stents: a systematic review and meta-analysis

BACKGROUND

Over-the-scope clips (OTSC), both conventional and Stentfix, are believed to anchor the self-expanding metal (SEMS) and prevent migration. We aimed to systematically study the efficacy of endoscopic OTSC fixation of SEMS in prevention of migration.

METHODS

We searched electronic databases from inception to November 11, 2022 to identify studies reporting outcomes of OTSC fixation of metal stents. The primary outcome was to calculate the pooled migration rates following OTSC anchorage of SEMS and to compare it with controls (SEMS without any fixation). The secondary outcomes include technical and clinical success of OTSC anchorage of SEMS. Random effect models were used to determine pooled rates of migration and technical as well as clinical success rates of OTSC anchorage of metal stents.

RESULTS

A total of 9 studies were included. The pooled rate of migration following OTSC anchorage of SEMS was 0.10 (95%CI, 0.04-0.20, I2 = 43%). The pooled rate of migration following OTSC anchorage of esophageal SEMS was 0.08 (95%CI, 0.04-0.15, I2 = 0%). The pooled risk ratio of SEMS migration following OTSC Stentfix was lower as compared to no fixation of SEMS [RR = 0.24 (95%CI,0.13- 0.43, I2 = 0)]. The pooled technical success rate of OTSC fixation following SEMS was 0.98 (95%CI, 0.81-1.00, I2 = 0%). The pooled clinical success rate of OTSC fixation following SEMS was 0.79 (95%CI, 0.64-0.88, I2 = 56%). All studies had valid and reliable methods to diagnose migration, technical and clinical success.

CONCLUSIONS

The use of OTSC clips (conventional or Stentfix) for anchorage had a lower risk of migration of metal stents than no fixation. Future studies should look into prospective multicenter studies on their use to prevent the migration of SEMS.

Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of  > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection.

Current status and perspectives for endoscopic diagnosis of superficial nonampullary duodenal epithelial tumors

In recent years, there have been significant advances in the endoscopic resection (ER) procedures of superficial nonampullary duodenal epithelial tumors (SNADETs). A preoperative endoscopic diagnosis is thus deemed necessary in determining the indication for subsequent ER. For the histologic and endoscopic diagnosis of SNADETs, understanding the mucin phenotype is inevitable. Recently, two diagnostic algorithms for the differential diagnosis of SNADETs from nonneoplastic lesions under magnifying endoscopy with narrow-band imaging have been proposed. In addition, various endoscopic approaches have been proposed to differentiate low- and high-grade adenomas/carcinomas, including white light endoscopy, magnifying image-enhanced endoscopy, and endocytoscopy. These methods, however, have not been standardized with respect to the classification of their findings and the validation of their diagnostic accuracy. Moreover, there are still concerns with respect to the histologic criteria required to establish a SNADETs diagnosis. Standardization in the histologic and endoscopic diagnosis of SNADETs is needed.

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.

Endoscopic Submucosal Dissection in the Stomach and Duodenum: Techniques, Indications, and Outcomes

Gastric endoscopic submucosal dissection (ESD) is established for management of early gastric cancer (EGC). Diagnosis of EGC relies on adequate endoscopic assessment involving lesion size, histopathology, presence of ulceration, and depth of invasion. Absolute indications for endoscopic resection of EGC are if patients are presumed to have a less than 1% risk of lymph node metasta endoscopic submucosal dissectionsis, and long-term outcomes are similar to those with surgical gastrectomy. Duodenal ESD is more technically difficult and requires expertise in ESD in other locations.

Laparoscopic Endoscopic Cooperative Surgery Using Open-Window Suturing Technique for Treating Non-ampullary Superficial Duodenal Neoplasms Located on the Pancreatic Side

PURPOSE

No study has focused on the safety and feasibility of our previously developed open-window suturing technique to close mucosal defects on the pancreatic side after endoscopic submucosal dissection from the opened duodenal wall. This study aimed to evaluate the safety and usefulness of laparoscopic endoscopic cooperative surgery for duodenal tumors for treating superficial non-ampullary duodenal epithelial tumors on the pancreatic side of the duodenum.

METHODS

This retrospective study included 61 consecutive patients who underwent surgery during August 2014-November 2021. After dissection when the tumor was on the pancreatic side, we sutured the mucosal defect from the opened duodenal wall. A preoperative endoscopic pancreatic stent was placed for tumors within 1 cm of the ampulla of Vater. The surgical outcomes were compared between tumors on the pancreatic and non-pancreatic sides.

RESULTS

There were 27 and 34 patients with tumors on the pancreatic and non-pancreatic sides, respectively. The patient characteristics were similar. Preoperative pancreatic stents were placed in four patients in the pancreatic side group. The median operative time was significantly longer on the pancreatic side than in the non-pancreatic side group (241 vs. 209 min, P = 0.02). In one patient in the pancreatic side group, an intraoperative injury of the ampulla of Vater was successfully treated with intraoperative management. There were no significant differences in the incidence of postoperative grade II or higher complications between the groups.

CONCLUSIONS

Laparoscopic endoscopic cooperative surgery for duodenal tumors for treating superficial non-ampullary duodenal epithelial tumors on the pancreatic side is safe and feasible.

Over-the-scope clip closure of gastric endoscopic submucosal dissection-induced ulcer in a patient with bleeding tendency

A man in his 70s, with a history of dementia and aplastic anemia, was diagnosed with a gastric tumor. Thrombocytopenia due to aplastic anemia may cause bleeding after endoscopic submucosal dissection. Then, ulcer closure using the over-the-scope clip system was performed for prevention of post-operative bleeding.

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 Case 2.

Outcomes of endoscopic resection for superficial duodenal tumors: 10 years' experience in 18 Japanese high volume centers

BACKGROUND

Data on endoscopic resection (ER) for superficial duodenal epithelial tumors (SDETs) are insufficient owing to their rarity. There are two main ER techniques for SDETs: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). In addition, modified EMR techniques, such as underwater EMR (UEMR) and cold polypectomy, are becoming popular. We conducted a large-scale retrospective multicenter study to clarify the detailed outcomes of duodenal ER.

METHODS

Patients with SDETs who underwent ER at 18 institutions from January 2008 to December 2018 were included. The rates of en bloc resection and delayed adverse events (AEs; defined as delayed bleeding or perforation) were analyzed. Local recurrence was analyzed using the Kaplan-Meier method.

RESULTS

In total, 3107 patients (including 1017 undergoing ESD) were included. En bloc resection rates were 79.1 %, 78.6 %, 86.8 %, and 94.8 %, and delayed AE rates were 0.5 %, 2.2 %, 2.8 %, and 6.8 % for cold polypectomy, UEMR, EMR and ESD, respectively. The delayed AE rate was significantly higher in the ESD group than in non-ESD groups for lesions < 19 mm (7.4 % vs. 1.9 %; P < 0.001), but not for lesions > 20 mm (6.1 % vs. 7.1 %; P = 0.64). The local recurrence rate was significantly lower in the ESD group than in the non-ESD groups (P < 0.001). Furthermore, for lesions > 30 mm, the cumulative local recurrence rate at 2 years was 22.6 % in the non-ESD groups compared with only 1.6 % in the ESD group (P < 0.001).

CONCLUSIONS

ER outcomes for SDETs were generally acceptable. ESD by highly experienced endoscopists might be an option for very large SDETs.

Effectiveness of clip-and-thread traction-assisted duodenal endoscopic submucosal dissection: a propensity score-matched study (with video)

BACKGROUND AND AIMS

The indications for endoscopic submucosal dissection (ESD) in superficial nonampullary duodenal epithelial tumors (SNADETs) remain controversial because the procedure is technically challenging. Moreover, the effectiveness of clip-and-thread traction-assisted ESD (TA-ESD) for SNADETs has not been assessed. The aim of the current study was to compare the effectiveness of duodenal TA-ESD and conventional ESD for SNADETs.

METHODS

SNADETs treated with conventional ESD or TA-ESD between April 2017 and March 2021 at Saitama Medical University International Medical Center were evaluated retrospectively.

RESULTS

There were 49 cases of conventional ESD and 32 cases of TA-ESD for SNADETs. Using a propensity score-matched design, we selected 26 pairs of cases with conventional ESD and TA-ESD. In the unmatched cohort, patients treated with TA-ESD were characterized by a higher R0 (no tumor identified at the lateral or vertical margins) resection rate (P = .004), more frequent poor submucosal lifting because of fibrosis (P = .014), and shorter follow-up period (P = .0004) than patients treated with conventional ESD. In the propensity score-matched pairs, patients treated with TA-ESD were characterized by a higher rate of R0 resection (P = .021) and a shorter follow-up period (P = .0061). The findings regarding R0 resection rates were confirmed by multivariate logistic regression models, which found a higher odds ratio (OR) for R0 resection in patients who underwent TA-ESD than in patients who underwent conventional ESD both in the unmatched cohort (OR, 17.0; 95% confidence interval, 1.6-178.8; P = .018) and in the propensity score-matched pairs (OR, 26.7; 95% confidence interval, 1.5-460.2; P = .024).

CONCLUSIONS

Our findings suggest TA-ESD may increase the rate of R0 resection in patients with SNADETs in comparison with conventional ESD.

Recent approach for preventing complications in upper gastrointestinal endoscopic submucosal dissection

Although endoscopic submucosal dissection (ESD) is a minimally invasive treatment method for upper gastrointestinal (GI) tumors, patients undergoing upper GI ESD sometimes fall into a serious condition from complications. Thus, it is important to fully understand how to prevent complications when performing upper GI ESD. One of the major complications in esophageal and gastric ESD is intraoperative perforation. To prevent this complication, blind dissection should be avoided. Traction-assisted ESD is a useful technique for maintaining good endoscopic view. This method was proven to reduce the incidence of intraoperative perforation, which would become a standard technique in esophageal and gastric ESD. In gastric ESD, delayed bleeding is the most common complication. Recently, a novel prediction model (BEST-J score) consisting of 10 factors with four risk categories for delayed bleeding in gastric ESD was established, and a free mobile application is now available. For reducing delayed bleeding in gastric ESD, vonoprazan ≥20 mg/day is the sole reliable method in the current status. Duodenal ESD is still challenging with a much higher frequency of complications, such as perforation and delayed bleeding, than ESD in other organs. However, with the development of improved devices and techniques, the frequency of complications in duodenal ESD has been decreasing. To prevent intraoperative perforation, some ESD techniques, such as using the distal tips of the Clutch Cutter, were developed. An endoscopic mucosal defect closure technique would be mandatory for preventing delayed complications. However, several unresolved issues, including standardization of duodenal ESD, remain and further studies are demanded.

Endoscopic resection of superficial non‐ampullary duodenal epithelial tumor

Although superficial non‐ampullary duodenal epithelial tumor (SNADET) was previously considered a rare disease, in recent years, the opportunities to detect and treat SNADET are increasing. Considering the high morbidity of pancreatoduodenectomy, endoscopic resection can be a treatment option that preserves the organs and contributes maintain patients’ quality of life. Endoscopic mucosal resection (EMR) is a standard treatment for relatively small lesions in gastrointestinal tracts, however, it is difficult because submucosal fibrosis frequently occurs due to the previous biopsy. Recently, some modified EMR techniques including underwater EMR (UEMR) and cold polypectomy (CP) have been proposed. In UEMR, the duodenal lumen is filled with water or saline and resected the targe lesion with a snare without injection into the submucosa. It would be a treatment option that could reduce candidates for ESD especially SNADET less than 20 mm. CP was reported as a safe and convenient means for SNADET. It would also be one of the standard treatments for diminutive lesions, though there remain some concerns on its resectability. ESD for SNADET is technically challenging, especially with an extremely high risk of adverse event (AE) with a reported bleeding rate of more than 20% and perforation rate up to about 40%. However, modified treatment techniques including the water pressure method and pocket creation method have been reported to potentially contribute to improving outcomes of ESD. Moreover, accumulated evidence shows closing the mucosal defect significantly reduces delayed adverse events after duodenal endoscopic treatments. Further studies are warranted to elucidate curative criteria, long‐term outcomes, and appropriate surveillance strategy.

Endoscopic submucosal dissection for a laterally spreading ampullary carcinoma

Video 1We performed endoscopic submucosal dissection with the patient under conscious sedation. After making markings around the lesion, we incised the mucosa from the oral side of the ampullary lesion and dissected the submucosal layer using a Clutch Cutter. We created 2 submucosal tunnels to identify the dissection line of the ampulla. After completion of the tunnels, we performed a mucosal incision circumferentially and dissected the submucosal layer except the ampulla. Subsequently, we removed the ampulla directly above the muscle layer of the duodenum using the Clutch Cutter. En bloc resection was achieved. After resecting the lesion, a biliary stent and pancreatic stent were placed into the common bile duct and pancreatic duct, respectively. Prophylactic closure of the mucosal defect was performed using endoclips and a polyglycolic acid sheet with fibrin glue to prevent delayed perforation and bleeding.

Over-the-Scope Clip in the Treatment of Gastrointestinal Leaks and Perforations

While perforations, postoperative fistulas, and leaks have traditionally led to surgical or interventional radiology consultation for management, the introduction of the over-the-scope clip has allowed increased therapeutic possibilities for endoscopists. While primarily limited to case reports and series, the over-the-scope clip successfully manages gastrointestinal bleeding, perforations, as well as postoperative leaks and fistulas. Retrospective studies have demonstrated a relatively high success rate and a low complication rate. Given the similarity to variceal banding equipment, the learning curve with the over-the-scope clip is rapid. However, given the higher risk of procedures involving the use of the over-the-scope clip, it is essential to obtain the scope in a stable position and grasp sufficient tissue with the cap using a grasping tool and/or suction. From our experience, while closure may be successful in lesions sized up to 3 cm, successful outcomes are obtained for lesions sized <1 cm. Ultimately, given the limited available data, prospective randomized trials are needed to better evaluate the utility of the over-the-scope clip in various clinical scenarios, including fistula and perforation management.

Current Treatment Strategy for Superficial Nonampullary Duodenal Epithelial Tumors

Endoscopic submucosal dissection (ESD) is the standard treatment method for esophageal, gastric, and colorectal cancers. However, it has not been standardized for duodenal lesions because of its high complication rates. Recently, minimally invasive and simple methods such as cold snare polypectomy and underwater endoscopic mucosal resection have been utilized more for superficial nonampullary duodenal epithelial tumors (SNADETs). Although the rate of complications associated with duodenal ESD has been gradually decreasing because of technical advancements, performing ESD for all SNADETs is unnecessary. As such, the appropriate treatment plan for SNADETs should be chosen according to the lesion type, patient condition, and endoscopist’s skill.

Advances in endoscopic therapy using grasping-type scissors forceps (with video)

Endoscopic submucosal dissection (ESD) is a globally accepted minimally invasive therapy for early-stage gastrointestinal tract tumors. Although numerous electrosurgical knives have been developed for ESD, technical difficulties and high complication rates (bleeding and perforation) have limited their use worldwide. The grasping-type scissors forceps [clutch cutter (CC)] is the first forceps-type resection device developed with reference to hemostatic forceps. The aim was to allow easy and safe ESD throughout the gastrointestinal tract, as a biopsy technique, using one device. The CC can grasp the target tissue accurately and pull it away from the underlying muscle layer prior to energizing the tissue, for safe and effective incision and hemostasis during ESD. Reported clinical studies showed that ESD using the CC (ESD-CC) is a safe (perforation rate: 0%-3.6%; delayed bleeding rate: 0%-4.2%), technically efficient (en-bloc resection rate: 88.9%-100%), and single-device method for dissecting early-stage gastrointestinal tract tumors. The ESD-CC technique is simple and easy to learn because it can be completed simply by repeating the grasp, pull, and coagulate and/or incise actions using an electrosurgical current. The reported self-completion rate by non-experts was significantly better with the CC than with conventional knives (61.7% vs 24.5%, respectively; P < 0.001). Furthermore, the CC is used for other endoscopic therapies, such as endoscopic polypectomy for large pedunculated polyps, endoscopic myotomy for Zenker’s diverticulum, endoscopic treatment of buried bumper syndrome, and endoscopic necrosectomy for wall-off pancreatic necrosis. The initial reports using CC for these therapies have shown favorable results. In this review, we describe the structural features of the CC, how to use the instrument, efficacies of ESD-CC, and other unique endoscopic therapies using the CC.

The mucin phenotype does not affect the endoscopic resection outcome of non-ampullary duodenal epithelial tumors

Background and study aims  Some studies have reported an association between clinicopathological features and mucin phenotypes of non-ampullary duodenal epithelial tumors (NADETs). However, the association between clinical outcomes of endoscopic resection (ER) and mucin phenotypes has not been elucidated. The aim of this retrospective study was to analyze clinical outcomes of ER of NADETs with reference to mucin phenotypes. Patients and methods  We retrospectively evaluated the clinical outcomes of ER for NADETs performed from 2006 to 2019 and compared clinicopathological characteristics, ER procedures, and outcomes, including adverse events (AEs) among tumors classified by mucin phenotype. Mucin phenotypes were classified as gastric, gastrointestinal, and intestinal based on immunohistochemical examination. Grade of dysplasia was determined according to the Vienna classification (VCL). Results  The proportion of VCL 4/5 was higher in the gastric type (50 %) compared with that in the gastrointestinal (39.1 %, P  = 0.009) and intestinal types (5.4 %, P  = 0.008), respectively. With no statistical difference in tumor size and ER method among the three groups, no significant difference was observed for ER outcomes, i. e., en bloc and R0 resection rates. In the gastrointestinal and intestinal types, AEs occurred in four cases treated with ESD, but none developed in the gastric type. Conclusions  This study suggests that the mucin phenotype does not affect resection outcome. However, considering high malignant potential and tendency for low AE rates, the gastric type NADETs may be more appropriate for proactive ER than the others.

Clinical Impact of Different Reconstruction Methods on Remnant Gastric Cancer at the Anastomotic Site after Distal Gastrectomy

Background/Aims

The anastomotic site after distal gastrectomy is the area most affected by duodenogastric reflux. Different reconstruction methods may affect the lesion characteristics and treatment outcomes of remnant gastric cancers at the anastomotic site. We retrospectively investigated the clinicopathologic and endoscopic submucosal dissection outcomes of remnant gastric cancers at the anastomotic site.

Methods

We recruited 34 consecutive patients who underwent endoscopic submucosal dissection for remnant gastric cancer at the anastomotic site after distal gastrectomy. Clinicopathology and treatment outcomes were compared between the Billroth II and non-Billroth II groups.

Results

The tumor size in the Billroth II group was significantly larger than that in the non-Billroth II group (22 vs. 19 mm; p=0.048). More severe gastritis was detected endoscopically in the Billroth II group (2 vs. 1.33; p=0.0075). Moreover, operation time was longer (238 vs. 121 min; p=0.004) and the frequency of bleeding episodes was higher (7.5 vs. 3.1; p=0.014) in the Billroth II group.

Conclusions

Compared to remnant gastric cancers in non-Billroth II patients, those in the Billroth II group had larger lesions with a background of severe remnant gastritis. Endoscopic submucosal dissection for remnant gastric cancers in Billroth II patients involved longer operative times and more frequent bleeding episodes than that in patients without Billroth II.

Current status of endoscopic diagnosis and treatment for superficial non-ampullary duodenal epithelial tumors

Though superficial non-ampullary duodenal epithelial tumors (SNADETs) have been traditionally considered rare, there is a growing detection under the development and widespread of endoscopic techniques in recent times. Many case studies have revealed early manifestations of lesions through advanced endoscopic technology, however, because of the low incidence of duodenal tumors and challenges in diagnosing, the preoperative diagnosis criteria have not been established so far. In spite of this, recently the increasing detection rate of early duodenal epithelial lesions enhances the demand for minimally invasive treatment as well. The most suitable therapeutic endoscopic modality to remove duodenal lesions should be selected according to the size, location and histological invasive depth of duodenal lesions. Nevertheless, due to the special anatomical structure of the duodenum, the incidence of complications is much higher than in any other part of the digestive tract. To prevent these adverse events prophylactically, a few novel strategies have been applied effectively after resection. This review describes the current status of preoperative endoscopic diagnosis and endoscopic resection approaches, as well as countermeasures for avoiding procedure-related complications.

Endoscopic resection using an over-the-scope clip for duodenal neuroendocrine tumors

Background and study aims  Endoscopic resection of duodenal neuroendocrine tumors (DNETs) remains controversial, and its indications are still unclear. This study aimed to evaluate short-term outcomes of a newly developed endoscopic muscularis resection (EMR) method that utilizes an over-the-scope clip (OTSC), termed EMRO, for treating DNETs. Patients and methods  In total, 13 consecutive patients with 14 small (≤ 10 mm) DNETs who underwent EMRO from September 2017 to March 2020 were retrospectively enrolled. EMRO was performed by a single experienced endoscopist. Patients' characteristics and treatment outcomes were assessed. Results  The En bloc and R0 resection rates were 100 % (14/14) and 92.9 % (13/14), respectively. The median pathological resected specimen size was 10 mm, with a median pathological resected tumor size of 6 mm. During the EMRO procedure, there was no occurrence of misplacement of the OTSC to the target lesion. With respect to the pathological resection depth, nine cases (64.3 %) and five cases (35.7 %) were categorized as deep submucosal resection and muscularis resection, respectively, whereas no case was categorized as full-thickness resection. There were no intraoperative or delayed perforations. However, delayed bleeding occurred in two cases. At a median follow-up of 12 months (range 7-36) after EMRO, there was no incidence of local recurrence. At the first follow-up endoscopy performed at 6 months after EMRO, the OTSC was retained in place in two of 14 DNETs (14.3 %). Conclusions  EMRO can be performed safely, by an experienced endoscopist, for small (≤ 10 mm) DNETs.

Over-the-Scope Clip-Associated Endoscopic Muscular Dissection for Seven Cases of Small Gastric Submucosal Tumor: A Video-Based Case Series

Objectives

To evaluate the methodology, feasibility, safety, and efficacy of a novel method called over-the-scope clip- (OTSC-) associated endoscopic muscular dissection for small GSMT.

Methods

A pilot study on small GSMT diameter ≤ 1 cm was performed. OTSC-associated endoscopic muscular dissection was based on the requirement of OTSC apparatus and ESD technique; after ligaturing the bottom of small GSMT by OTSC, ESD was performed to resect the tumors, and the wounds of ESD were closed by clips finally. All the patients were followed up for more than 3 months, and the complications during and after OTSC-associated endoscopic muscular dissection were recorded.

Results

A total of 7 consecutive patients with small GSMT were included. All tumors were completely dissected without any perforation or infection during and after the procedure in all cases, while three patients had mild abdominal pain, and one experienced postoperative bleeding after the procedure which was treated by the endoscopy with titanium clips. All the patients were followed by endoscopy three months later, all the wounds healed well, and all the OTSCs were still in the gastric wall.

Conclusions

OTSC-associated endoscopic muscular dissection as a novel endoscopic interventional therapy should be a convenient, safe, and effective therapy for small GSMT. The short-time outcome is excellent, whereas long-term effect is unclear, and the further follow-up is needed to schedule.

Risk factors of delayed bleeding after endoscopic resection of superficial non-ampullary duodenal epithelial tumors and prevention by over-the-scope and conventional clipping

OBJECTIVES

This study was aimed to reveal risk factors for delayed bleeding after endoscopic resection (ER) of superficial non-ampullary duodenal epithelial tumors (SNADETs) and at exploring measures to prevent this complication.

METHODS

A total of 235 consecutive patients with 249 SNADETs who had undergone ER were enrolled in this study. They were divided into two groups: OTSC group, consisting of the initial 114 cases in which the defects were closed only using OTSCs; and OTSC-c group, consisting of the later 135 cases in which conventional clips were additionally used to cover the inverted submucosa after post-procedure defect closure using OTSCs. The therapeutic outcomes were then compared between the OTSC and OTSC-c groups.

RESULTS

All lesions were successfully resected en-bloc, and the R0 resection rate was 92.4%. The complete defect closure rate was 90.0% and no delayed perforation occurred when successful defect closure was achieved. The rate of delayed bleeding was significantly higher in the OTSC group than in OTSC-c group (11.4% vs. 1.5%, P = 0.001). Multivariate logistic regression analyses revealed that tumor location distal to the ampulla (OR 10.0; 95% CI 1.24-81.0, P = 0.03) and use of a DOAC (OR 8.83; 95% CI 1.13-68.7, P = 0.04) were significant independent predictors of delayed bleeding. Propensity score-matching analysis revealed that additional use of conventional clips was associated with a significantly reduced risk of delayed bleeding (P = 0.003).

CONCLUSIONS

Additional use of conventional clips after prophylactic defect closure using OTSCs appears to be useful to reduce the risk of delayed bleeding after ER of SNADETs. UMIN Clinical Trials (No. 000035478).

Feasibility of laparoscopic endoscopic cooperative surgery for non-ampullary superficial duodenal neoplasms: Single-arm confirmatory trial

OBJECTIVE

Laparoscopic endoscopic cooperative surgery for duodenal tumors (D-LECS) has been developed to prevent duodenal leakage by reinforcing the endoscopic submucosal dissection site. However, there has been no prospective trial showing the feasibility of D-LECS. Herein, we conducted a single-arm confirmatory trial to evaluate the safety of D-LECS for non-ampullary superficial duodenal neoplasms.

METHODS

This prospective single-center single-arm confirmatory trial analyzed patients with non-ampullary superficial duodenal neoplasms who underwent D-LECS. The primary endpoint was the incidence of any postoperative leakage occurring on the duodenal wall within 1 month postoperatively. The planned sample size was 20 patients, considering a threshold of 28% and one-sided alpha value of 5%.

RESULTS

Between January 2015 and September 2018, 20 eligible patients were enrolled. Sixteen tumors were located in the second portion, three in the first portion, and one in the third portion of the duodenal region. The median operative time was 225 (134-361) min and the median blood loss was 0 (0-150) mL. Curative resection (R0) with negative margins was achieved in 19 cases. One case of postoperative leakage and one case of bleeding of grade 2 according to the Clavien-Dindo classification were observed in this series. The median duration of postoperative hospital stay was 9 (5-12) days. No local recurrence was observed in any patient during the median follow-up of 15.0 (12.0-38.0) months.

CONCLUSIONS

This trial confirmed the safety and feasibility of D-LECS for non-ampullary superficial duodenal neoplasms with respect to the low incidence of postoperative duodenal leakage.

Establishment of an in-vivo porcine delayed perforation model after duodenal endoscopic submucosal dissection

OBJECTIVES

Duodenal endoscopic submucosal dissection (ESD) for superficial non-ampullary duodenal epithelial tumors has a significant incidence rate of delayed perforation. Although several methods have been proposed to prevent delayed perforation, the most appropriate methods remain unclear. Currently, there is no appropriate animal model to validate methods for preventing duodenal delayed perforation. This study aimed to establish an in-vivo porcine delayed perforation model after duodenal submucosal dissection.

METHODS

Two porcine models underwent either ESD or surgical submucosal dissection. In the surgical dissection model, an inverted duodenal mucosa was resected with electrosurgical energy. In the ESD model, a gauze was placed behind the duodenum with grasped transverse part to improve endoscopic maneuverability. The mucosal defects after dissection were treated with omental coverage without suture in both models. All models were euthanized 0-5 days after procedure. Body weight; resection size; procedure dissection time; presence of intraoperative perforation and delayed perforation; and adhesion score were assessed.

RESULTS

There were no significant differences in body weight and adhesion score between the two models. Resection size was significantly larger in the surgical dissection models than in the ESD models (19 mm vs 14.3 mm, P < 0.01). Procedure time was significantly longer in the ESD models than in the surgical models (45.2 minutes vs 4.5 minutes, P < 0.01). Delayed perforation rates in the surgical dissection models and the ESD models were 0% (0/5) and 100% (5/5), respectively (P < 0.01).

CONCLUSIONS

This study indicated that our in-vivo porcine duodenal ESD model is beneficial to evaluate a prevention strategy for delayed perforation.

White light and/or magnifying endoscopy with narrow band imaging for superficial nonampullary duodenal epithelial tumors

BACKGROUND AND AIM

A reliable optical diagnosis of superficial nonampullary duodenal epithelial tumors (SNADETs) to guide optimal treatment strategy is lacking. The aim of this study was to simulate the treatment outcomes based on optical diagnosis using white light imaging (WLI) or magnifying endoscopy with narrow band imaging (MNBI) and to evaluate the method to extract optimal lesions suitable for cold snare polypectomy (CSP) or not.

METHODS

We created a decision tree model using WLI and MNBI diagnosis for ideal treatment for SNADETs. Optical diagnoses of Vienna category 3 lesions (C3), category 4/5 (C4/5) were defined based on the WLI scoring system or the MNBI pattern diagnosis. Ideal treatments were CSP for C3 < 10mm, and endoscopic mucosal resection, endoscopic submucosal dissection or surgery for lesions ≥10mm or C4/5. Ideal treatment results based on optical diagnosis were analyzed according to actual pathological results.

RESULTS

A total of 218 lesions with pre-operative diagnosis of SNADETs were included for analysis. Percentage of ideal treatment for C3 < 10mm based on WLI or MNBI or both was 88%, 83% and 97%. When WLI and MNBI diagnoses predicted the same histology, the specificity, positive predictive value and accuracy were significantly higher than those of WLI or MNBI alone (p < .05).

CONCLUSIONS

A decision tree model using lesion diameter, WLI scoring and MNBI pattern diagnosis is hypothetically useful to select ideal lesions for CSP among SNADETs. Optical diagnosis using both WLI and MNBI is more useful than WLI or MNBI alone.

Application of endoscopic submucosal dissection in duodenal space-occupying lesions

BACKGROUND

Endoscopic submucosal dissection (ESD) has been advocated by digestive endoscopists because of its comparable therapeutic effect to surgery, reduced trauma, faster recovery, and fewer complications. However, ESD for lesions of the duodenum is more challenging than those occurring at other levels of the gastrointestinal tract due to the thin intestinal wall of the duodenum, narrow intestinal space, rich peripheral blood flow, proximity to vital organs, and high risks of critical adverse events including intraoperative and delayed bleeding and perforation. Because of the low prevalence of the disease and the high risks of severe adverse events, successful ESD for lesions of the duodenum has rarely been reported in recent years.

AIM

To investigate the efficacy and safety of ESD in the treatment of duodenal space-occupying lesions.

METHODS

Clinical data of 24 cases of duodenal lesions treated by ESD at the Digestive Endoscopy Center of the Affiliated Hospital of Qingdao University from January 2016 to December 2019 were retrospectively analyzed.

RESULTS

All of the 24 cases from 23 patients underwent ESD treatment for duodenal space-occupying lesions under general anesthesia, including 15 male and 8 female patients, with a mean age of 58.5 (32.0-74.0) years. There were 12 lesions (50%) in the duodenal bulb, 9 (37.5%) in the descending part, and 3 (12.5%) in the ball-descending junction. The mean diameter of the lesion was 12.75 (range, 11-22) mm. Thirteen lesions originated from the mucosa, of which 4 were low-grade intraepithelial neoplasia, 3 were hyperplastic polyps, 2 were chronic mucositis, 2 were adenomatous hyperplasia, 1 was high-grade intraepithelial neoplasia, and 1 was tubular adenoma. Eleven lesions were in the submucosa, including 5 neuroendocrine neoplasms, 2 cases of ectopic pancreas, 1 stromal tumor, 1 leiomyoma, 1 submucosal duodenal adenoma, and 1 case of submucosal lymph follicular hyperplasia. The intraoperative perforation rate was 20.8% (5/24), including 4 submucosal protuberant lesions and 1 depressed lesion. The mean length of hospital stay was 5.7 (range, 3-10) d, and the average follow-up time was 25.8 (range, 3.0–50.0) mo. No residual disease or recurrence was found in all patients, and no complications, such as infection and stenosis, were found during the follow-up period.

CONCLUSION

ESD is safe and effective in the treatment of duodenal lesions; however, the endoscopists should pay more attention to the preoperative preparation, intraoperative skills, and postoperative treatment.

Ex vivo porcine model study on the treatment outcomes of scissor-type knife versus needle-type knife in endoscopic submucosal dissection performed by trainees

BACKGROUND

Endoscopic submucosal dissection (ESD) for gastrointestinal neoplasms can be technically difficult for trainee endoscopists. Presently, there is no consensus for trainees to select the endo-knife type in ESD. Therefore, we conducted a comparison study of treatment outcomes between scissors-type and needle-type knives in ESD performed by trainees in an ex vivo porcine model.

METHODS

This study was conducted on trainee endoscopists who participated in ESD hands-on seminars held in August 2018 and September 2019. A total of 22 trainees from 13 institutions were divided into two groups according to their endoscopic experience. Under expert supervision, each trainee performed two ESDs in porcine models, namely, scissor-type knife (ESD-S) and needle-type knife (ESD-N). The efficacy and safety, including the procedure time and rates of self-completion, en bloc resection, and complications, were compared between ESD-S and ESD-N. In subgroup analysis, we also investigated the predictors associated with the difficulty of ESD for trainees using multivariate logistic regression analysis.

RESULTS

Eight trainees had an experience of over 1000 endoscopies (senior trainee: S-Trainee), whereas the others had an experience of less than 1000 endoscopies (junior trainee: J-Trainee). Among the S-Trainees, no significant differences were observed in any treatment outcome between ESD-S and ESD-N. Among the J-Trainees, the total procedure and mucosal incision times were significantly shorter in ESD-S than in ESD-N [total procedure time: 16.5 min (range 10.0-31.0) vs. 22.3 min (range 10.0-38.0), P = 0.018; circumferential incision time: 10.0 min (range 6-16) vs. 17.0 min (range 5.0-31.5); P = 0.019]. Regarding complications, muscular injury occurred in two patients during ESD-N performed by J-Trainees; however, no muscular injury occurred during ESD-S. In subgroup analysis, ESD-N was an independent predictive factor of difficult ESD (odds ratio 5.28, 95% confidence interval 1.25-22.30; P = 0.024).

CONCLUSIONS

This study revealed that trainees, particularly those who have experienced less than 1000 endoscopies, should opt for the scissor-type knife to perform ESD.

Current Challenge: Endoscopic Submucosal Dissection of Superficial Non-ampullary Duodenal Epithelial Tumors

With the widespread use of esophagogastroduodenoscopy in recent years, the detection rate of superficial non-ampullary duodenal epithelial tumors (SNADETs) is increasing. Most SNADETs are early-stage adenocarcinoma or benign conditions, including adenoma. Therefore, endoscopic resection is desirable from the perspective of quality of life. However, endoscopic resection for SNADETs has not yet been established. Endoscopic submucosal dissection (ESD) is the most promising method for the treatment of SNADETs, because ESD provides a high rate of en bloc resection and a low rate of recurrence regardless of the tumor size. However, the difficulty of the procedure and a high rate of severe adverse events including perforation and bleeding have become major problems. Various preventive countermeasures for adverse events, such as use of specific devices, endoscope stabilization methods, and endoscopic closure of the post-ESD ulcer using clips, are reported to reduce the risk of the adverse events of ESD for SNADETs. This article reviews and highlights the current state of ESD for SNADETs and new challenges towards safe and effective ESD.