A 68-year-old man with type 2 diabetes and hypertension underwent upper gastrointestinal
endoscopy for anemia, revealing an ulcerated subepithelial lesion on the anterior-superior
wall
of the duodenal bulb ([Fig. 1]
a). Endoscopic ultrasound revealed a 25-mm hypoechoic lesion
arising from the submucosa and extending into the muscularis propria, with increased
vascularity
([Fig. 1]
b, c).
Fig. 1 Initial investigations. a Ulcerated subepithelial lesion in the duodenal bulb (D1). b Endoscopic ultrasound showing a 25-mm hypoechoic lesion arising from the submucosa
and extending into the muscularis propria. c Endoscopic ultrasound with Doppler demonstrating increased vascularity within the
lesion.
Computed tomography (CT) and positron emission tomography-CT confirmed a localized
lesion without nodal or distant spread ([Fig. 2]). Based on these features, endoscopic full-thickness resection (EFTR) was planned.
Fig. 2 Computed tomography (CT) imaging. a–c Ga-68 DOTA-TOC positron emission tomography with CT showing a tracer-avid (maximum
standardized uptake value: 178.3), well-defined, intensely arterially enhancing polypoidal
soft tissue lesion (arrow) in the duodenum (D1) along the medial aspect.
The procedure was performed under general anesthesia. Initial dissection with conventional
EFTR using carbon dioxide insufflation was limited by poor maneuverability, presence
of fibrosis, and bleeding. The approach was converted to saline-immersion therapeutic
endoscopy (SITE). Swift Coagulation (effect 3.5) was used to safely coagulate vessels
without a coagulation grasper, minimizing the risk of perforation.
An intermuscular dissection technique was employed to target the space between the
inner and outer muscularis propria, avoiding EFTR when possible. Only a <6-mm area
required EFTR due to deep invasion. This approach minimized peritoneal exposure and
avoided pneumoperitoneum ([Fig. 3], [Video 1]). The resection site was closed using the loop-and-clip technique. No complications
occurred.
Fig. 3 Endoscopy images. a–c Endoscopic intermuscular dissection using saline-immersion therapeutic endoscopy,
showing the space between the inner and outer muscularis propria. d Resection site demonstrating predominant intermuscular dissection with a small area
(<6 mm) of endoscopic full-thickness resection where the lesion extended into the
muscularis propria (arrows). e Defect closed using the loop-and-clip technique. f Resected tumor.
Saline immersion and intermuscular dissection enabled safe resection of a duodenal
neuroendocrine tumor involving the muscularis propria, minimizing full-thickness resection
and preventing procedural complications.Video 1
Histology confirmed a well-differentiated neuroendocrine tumor, infiltrating the muscularis
propria, with negative lateral and vertical margins and no lymphovascular invasion
([Fig. 4]).
Fig. 4 Histology. a Well-differentiated (G1) neuroendocrine tumor with Ki-67 index <2%. b Negative resection margins; inset demonstrates tumor cell infiltration into the muscularis
propria.
Endoscopic resection of duodenal lesions involving the muscularis propria is challenging
due to the thin wall, narrow lumen, and proximity to important vessels [1]. While EFTR offers an alternative to surgery, it carries risks such as pneumoperitoneum
and bleeding [2].
This video demonstrates a combined approach using the advantages of SITE-enhanced
visualization, elimination of gas insufflation, buoyancy-assisted traction, and reduced
thermal injury through gradual coagulation enabled by improved conductivity [3]
[4] (“frozen tree” effect). Furthermore, intermuscular dissection [5] enabled a targeted approach, limiting EFTR to only the extent necessary for complete
tumor removal, highlighting its value in anatomically challenging cases.
Endoscopy_UCTN_Code_TTT_1AO_2AC
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
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by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
