Endoscopic submucosal dissection (ESD) is widely used for the resection of superficial
gastrointestinal neoplasms. Previously, we reported that the pocket-creation method
(PCM) overcomes difficulties in ESD, such as in duodenal lesions [1] and subpedunculated neoplastic lesions [2]. Here, we describe the use of the PCM to facilitate ESD of a jejunal lesion.
A 54-year-old woman with familial adenomatous polyposis was referred for resection
of a large adenoma in the proximal jejunum. Laparotomy would have been difficult owing
to adhesions from previous surgery. Good maneuverability was confirmed in the vicinity
of the lesion by double-balloon endoscopy ([Fig. 1]), and we performed ESD using the PCM and balloon-assisted endoscopy (BAE).
Fig. 1 Advantages of balloon-assisted endoscopy (BAE) compared with push enteroscopy. a Push enteroscopy becomes unstable owing to stretching of the gastric and duodenal
walls. b By using BAE, the overtube with a balloon prevents a redundant loop, enabling accurate
and stable operation without paradoxical movements.
An endoscope with a 3.2-mm working channel (EI-580BT; Fujifilm, Tokyo, Japan) and
a small-caliber-tip transparent hood (ST hood; DH-15GR; Fujifilm) were used. The endoscope
tip balloon was not attached because the lesion was located in the upper jejunum.
The Hook knife (Olympus, Tokyo, Japan) was used for most of the dissection. The key
feature of the PCM is entering and dissecting the submucosal layer to make a pocket
using an ST hood after a minimal mucosal incision ([Fig. 2]). After creation of the submucosal pocket under the entire tumor, an additional
mucosal incision was made and submucosal dissection performed. Use of the PCM for
ESD with BAE safely achieved an en bloc resection of the tumor ([Video 1]).
Fig. 2 An endoscopic image and schema of the pocket-creation method of endoscopic submucosal
dissection for jejunal neoplastic lesions. a Endoscopic image in a submucosal pocket after creation of the submucosal pocket under
the entire tumor. b Schema at the time the pocket was completed.
Video 1 The pocket-creation method for endoscopic submucosal dissection of a jejunal adenoma.
The PCM has four main advantages including: (i) maintaining a thick submucosal layer
with a minimal incision; (ii) obtaining good traction by using an ST hood; (iii) conquering
the vertical approach by adjusting the direction of the endoscope tip; and (iv) stabilizing
the endoscope tip by synchronizing the endoscope and the pocket [1]. By using BAE, the overtube with a balloon prevents formation of a redundant loop,
enabling accurate and stable operation without paradoxical movements ([Fig. 1]) [3].
Endoscopy_UCTN_Code_TTT_1AP_2AD
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