Clip and dental floss traction-assisted endoscopic mucosal resection for early carcinoma of the duodenal papilla

 

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Endoscopic papillectomy was first reported in Japan in 1983 [1]. It is currently recognized as an alternative to surgical resection for ampullary neoplasms, and has a higher success rate and fewer adverse events compared with open surgery [2]. At present, there are many methods of endoscopic papillectomy, but there are differences in the complete resection rate, complications, operative difficulty, and other aspects between the various methods [3] [4]. There is still a lack of consensus on the optimal method. In particular, there is controversy about whether submucosal injection is necessary [4] [5]. We propose a compromise and relatively simple innovative method, which can improve the complete resection rate of residual tissue after submucosal injection, and provide a new idea for the endoscopic resection of difficult papillary lesions.

A 75-year-old woman who was asymptomatic was diagnosed with a duodenal papillary tubular adenoma, with focal mucosal high grade intraepithelial neoplasia on physical examination. It was planned for her to undergo endoscopic therapy. After she had given informed consent, the patient was managed under general anesthesia. The procedure was successfully carried out as follows ([Video 1]). First, a mixture of methylene blue and normal saline was injected into the submucosa around the papilla with a needle, and the lesion lifted well. A snare device was then inserted via the endoscope biopsy port and adjusted to grasp the lesion, which was excised using electrocautery ([Fig. 1 a]). There was however still residual tissue in the center of the wound ([Fig. 1 b]). Therefore, a clip combined with dental floss was used for traction-assisted lifting and exposure of the residual tissue ([Fig. 1 c]), and the same snare was used again to successfully remove the residual tissue ([Fig. 1 d, e]).

Video 1 Complete resection of a duodenal papillary lesion using clip and dental floss traction-assisted endoscopic mucosal resection of the residual tissue.

Although clip and dental floss traction-assisted endoscopic mucosal resection may be the preferable method for resection of early carcinoma of the duodenal papilla, further studies with more cases will be needed to validate the advantages of this technique.

Endoscopy_UCTN_Code_TTT_1AR_2AD

Publication History

Article published online:
16 February 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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• References

• 1 Suzuki K, Kantou U, Murakami Y. et al. Two cases with ampullary cancer who underwent endoscopic excision. Prog Dig Endosc 1983; 23: 236-239
  PubMedGoogle Scholar
• 2 Pyo JS, Son BK, Lee HY. et al. A comparison of clinical outcomes between endoscopic resection and surgical resection in ampullary tumors. Medicina 2020; 56: 546-556
  CrossrefPubMedGoogle Scholar
• 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
  CrossrefPubMedGoogle Scholar
• 4 Jeska AF, Paul F, Marc B. et al. Expert consensus on endoscopic papillectomy using a Delphi process. Gastrointest Endosc 2021; 94: 760-773
  CrossrefPubMedGoogle Scholar
• 5 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
  Article in Thieme ConnectPubMedGoogle Scholar