Miniprobe ultrasonography guidance during endoscopic submucosal dissection of an ampullary duodenal lesion

Endoscopic submucosal dissection (ESD) of ampullary lesions is an alternative to endoscopic papillectomy [1], which has several drawbacks such as a significant perforation rate, bleeding, and a low curative resection rate [2] [3] [4]. ESD may overcome these drawbacks, except for the risk of perforation. The sphincter of Oddi often cannot be distinguished from the duodenal muscularis. We report a novel technique using miniprobe ultrasonography to identify the sphincter of Oddi, which facilitates appropriate dissection just above the muscularis propria.

A 51-year-old woman was found to have an ampullary lesion (> 2 cm) during screening esophagogastroduodenoscopy ([Fig. 1]). Biopsy showed a high grade adenoma. Endoscopic ultrasonography revealed no findings suspicious for deep invasion. ESD was therefore attempted aiming to remove the lesion with negative margins ([Video 1]).

Fig. 1 White-light endoscopic view of an ampullary tumor larger than 2 cm.

Video 1 Endoscopic submucosal dissection of an ampullary duodenal lesion is performed with microprobe ultrasound guidance.

Download Video

A therapeutic endoscope (H-290T; Olympus, Tokyo, Japan) was used for the procedure and, after submucosal injection, an initial mucosal incision (approximately 15-mm long) was made 10 mm from the proximal side of the tumor using a needle-type knife (FlushKnife BT-S; 1.5 mm; Fujifilm, Tokyo, Japan). Submucosal pockets were created on both lateral sides of the ampulla ([Fig. 2]). A miniprobe was inserted into the left-sided submucosal pocket. Ultrasonography clearly depicted the sphincter of Oddi and duodenal muscularis, and an appropriate dissection line was identified ([Fig. 3]). The sphincter of Oddi was dissected from the muscularis using a scissor-type knife (SB Knife Jr. 2; SB KAWASUMI, Kanagawa, Japan) with Endocut I mode (VIO3; effect 1, duration 4, interval 1) to minimize thermal damage to the pancreaticobiliary ducts ([Fig. 4]). The remaining area was dissected and an en bloc resection was achieved. A duodenoscope was then used during placement of bile and pancreatic duct stents, and the mucosal defect was closed using endoclips ([Fig. 5]). There were no adverse events. The pathologic diagnosis was a high grade adenoma with a negative cut margin.

Fig. 2 Endoscopic view showing the sphincter of Oddi, which was identified after creating submucosal pockets on both lateral sides of the ampulla.

Fig. 3 Miniprobe ultrasonography enabled differentiation of the sphincter of Oddi from the duodenal muscularis, and an appropriate dissection line was identified.

Fig. 4 Endoscopic view during dissection of the sphincter of Oddi using a scissor-type knife.

Fig. 5 Endoscopic image of the final appearance after placement of biliary and pancreatic stents and prophylactic closure of the mucosal defect using endoclips.

Submucosal ultrasonography in the pocket was useful to identify the appropriate dissection line and avoid perforation.

Endoscopy_UCTN_Code_TTT_1AS_2AD

Competing Interest

The authors declare that they have no conflict of interest.

• References

• 1 Dohi O, Ishida T, Doi T. et al. Endoscopic submucosal dissection for a laterally spreading ampullary carcinoma. VideoGIE 2021; 7: 79-81
• 2 Spadaccini M, Fugazza A, Frazzoni L. et al. Endoscopic papillectomy for neoplastic ampullary lesions: A systematic review with pooled analysis. United European Gastroenterol J 2020; 8: 44-51
• 3 Li SL, Li W, Yin J. et al. Endoscopic papillectomy for ampullary adenomatous lesions: A literature review. World J Gastrointest Oncol 2021; 13: 1466-1474
• 4 Vanbiervliet G, Strijker M, Arvanitakis M. et al. Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53: 429-448

Publication History

Article published online:
10 October 2022