Endoscopic resection via antral submucosal tunneling for en bloc removal of tumors in the duodenal bulb.

To overcome difficulties in the removal of duodenal bulb lesions, especially those in anatomically challenging locations, we developed the endoscopic resection via antral submucosal tunneling (ERAST) technique. In this study, we evaluated the feasibility and safety of ERAST for the removal of superficial and subepithelial lesions in the duodenal bulb. This was a single-center retrospective study of 10 patients with lesions in the bulb. Submucosal tunneling from the gastric antrum to the duodenum was performed to facilitate en bloc tumor resection in the bulb. The en bloc resection rate, postoperative bleeding, and perforation were the primary endpoints. Ten lesions (four superficial and six subepithelial), with an average size of 19.1 ± 9.2 mm, were resected en bloc by ERAST. Esophagogastroduodenoscopy follow-up after 2 months indicated complete wound healing in all patients. In our primary experience, ERAST was found to be a feasible and safe endoscopic resection technique for the removal of lesions in the duodenal bulb, especially those that are difficult to access.

A snare combined with endoclips to assist in endoscopic submucosal dissection for intraepithelial neoplasia in the entire colon and rectum.

OBJECTIVE: The use of mucosal traction to assist in colonic and rectal endoscopic submucosal dissection (ESD), especially for deep colonic ESD, is challenging. We developed a method of inverse insertion of a snare into the endoscopic working channel to deliver it into the colon together with the endoscope. With this method, two types of mucosal traction, per-anal external traction (PET) and per-anal internal traction (PIT), could be achieved using a snare with endoclips to assist in ESD (ESD-SE). Here, we aimed to examine its safety and feasibility. METHODS: From January 2017 to September 2018, 50 colonic and rectal intraepithelial neoplasias in 50 patients were treated with ESD-SE. Data on lesion location and size, operation time, en bloc resection and R0 resection rates, and operative complications were collected. RESULTS: Among 50 lesions, 15 lesions were located in the deep colon/proximal colon, and 35 lesions were in the distal colon. The median (interquartile range) size of lesions, submucosal dissection time, and total operation time were 4.5 (3.0-5.0) cm, 32 (18-81) min, and 50 (33-108) min, respectively. All lesions were completely resected, with R0 resection rates of 100%. No intraoperative and postoperative complications occurred. Postoperative pathology revealed 40 and 10 cases of high-grade and low-grade intraepithelial neoplasia, respectively. CONCLUSIONS: The approach using insertion of a selective snare into the colon together with the endoscope, especially into the deep colon, was safe and simple. Use of the snare combined with endoclips could effectively assist in total colonic ESD. Further research is warranted.

Role of esophagogastroduodenoscopy in detecting distal duodenal lesions: A single-center pilot study in Southern China.

OBJECTIVE: Esophagogastroduodenoscopy (EGD) is a standard instrument for detecting upper gastrointestinal lesions. However, the distal duodenum is often missed. This study aimed to clarify the diagnostic role of EGD in the distal duodenum. METHODS: This retrospective study enrolled patients with distal duodenal lesions who underwent EGD between January 2004 and July 2016 at our center. The rate of missed diagnosis using EGD examination was calculated. Logistic regression analysis was performed to identify the factors associated with the missed diagnoses. RESULTS: Sixty-three patients were included in the study. The overall diagnostic rate of distal duodenal lesions on EGD was 58.7%. After excluding the patients in whom the EGD did not reach the distal duodenum, this rate rose to 82.2%. In univariate analysis, intravenous sedation (26.8% vs 68.2%, odds ratio [OR] 0.171, P = 0.002), signs of lesions adjacent to the stomach (19.4% vs 62.5%, OR 0.099, P = 0.001), prior enteroscopy experience (15.0% vs 87.0%, OR 0.026, P < 0.001), and endoscopists with experiences of over 10 years (13.8% vs 64.7%, OR 0.087, P = 0.000) were associated with a decreased risk of missed diagnosis. In multivariate analysis, signs of lesions adjacent to the stomach (OR 0.167, P = 0.039) and prior enteroscopy experience (OR 0.035, P < 0.001) were significant independent protective factors. CONCLUSION: EGD may be important in diagnosing distal duodenal lesions. Patients with gastric retention, blood in the stomach or erosion in the proximal duodenum may benefit from the deep insertion of EGD.

Cap-aspiration lumpectomy for small submucosal tumors originating from the muscularis propria of the gastric fundus: a preliminary study (with videos).

OBJECTIVE: Small fundal submucosal tumors (SMTs) originated from the muscularis propria pose great difficulties to conventional therapies. We aimed to evaluate the feasibility and safety of endoscopic cap-aspiration lumpectomy (CASL) as a new and simple full-thickness resection for the treatment of small fundal SMTs. METHODS: From July 2013 to February 2014, patients with small fundal SMTs of ≤10 mm in diameter that were originated from muscularis propria were included in the study. CASL was performed by suctioning SMTs into a transparent cap, ligating with a metal snare and resecting the tumors. The wall deficit was closed by using endoclips. RESULTS: Altogether 28 patients were included in the study. CASL achieved an en bloc resection rate of 100%, with a mean total procedure time of 23.9 min. Active perforation was found in 20 (71.4%) patients, and endoclips closed the wall defect in all 20 cases. One patient developed pneumoperitoneum and self-limited peritonitis was found in two patients, all of whom were managed successfully. Pathological examination showed that 71.4% (20/28) of the tumors were gastrointestinal stromal tumors. No tumor recurrence was observed during the follow-up. CONCLUSIONS: CASL may be a feasible and safe full-thickness resection modality for the treatment of small fundal SMTs arising from the muscularis propria. Further randomized studies are needed to confirm the results.