Duodenal endoscopic submucosal dissection is feasible using the pocket-creation method

Abstract

Duodenal endoscopic submucosal dissection (ESD) requires sophisticated endoscopic techniques because of a high rate of perforation. We introduced the pocket-creation method (PCM) of duodenal ESD to overcome difficulties. The aim of this study was to evaluate the safety and usefulness of ESD using the PCM for superficial tumors of the duodenum. We performed ESD of 17 non-ampullary duodenal lesions using the conventional method and of 28 lesions using the PCM from 2006 to 2015 and retrospectively reviewed the results, comparing the PCM and the conventional method. The median follow-up period was 35 months (range 2 - 97). There were more lesions at the duodenal angles in the PCM group compared with the conventional method group (54 % [15/28] vs. 22 % [4/17]; = 0.048), and the resected specimen diameter was larger in the PCM than the conventional method group (median 37 mm [range 25 - 101] vs. 25 mm [15 - 55]; = 0.007). Dissection speed was faster in the PCM than the conventional method group (9.4 mm/min [3.0 - 15.7] vs. 6.5 mm/min [1.5 - 19.7]; = 0.09). En bloc resection was more frequent in the PCM (100 % [28/28]) than the conventional method group (88 % [15/17]) ( = 0.07). Perforation was significantly less frequent in the PCM (7 % [2/28]) than the conventional method group (29 % [5/17]; = 0.046). The one delayed perforation in the conventional method group required surgical repair, while other intraprocedural perforations were treated by clipping. There were no recurrences. ESD of duodenal lesions can be safely performed using the PCM, which stabilizes the tip of the endoscope even in difficult locations.

Feasibility of underwater endoscopic mucosal resection and management of residues for superficial non‐ampullary duodenal epithelial neoplasms

“…A previous report showed that the “pocket creation method (PCM)” is effective for preventing adverse events during duodenal ESD and its intraprocedural perforation rate was 7%, but still higher than that in our trial. Additionally, median times in PCM were 106 min, which were longer compared with our study …”

“…In underwater conditions, superficial lesions float up into the snare as protruding lesions, the duodenal angles become obtuse, and the narrow duodenal lumen is constantly distended . A previous report showed that the “pocket creation method (PCM)” is effective for preventing adverse events during duodenal ESD and its intraprocedural perforation rate was 7%, but still higher than that in our trial. Additionally, median times in PCM were 106 min, which were longer compared with our study …”

“…Regarding the disadvantages of UEMR, the en bloc resection rate of UEMR was low (68%) compared with conventional ESD (88%) and PCM (100%), especially for large lesions (≥20 mm). In univariate analysis in the present study, large lesion size and piecemeal resection were more frequently observed in residual lesions than in non‐residual lesions.…”

Current Status and Challenges of Endoscopic Treatments for Duodenal Tumors

“…Once in the submucosal layer, the subsequent submucosal dissection becomes relatively easy and safe. Miura et al [22] also reported the pocket-creation method, which involves making a pocket in the submucosal layer with a minimal initial mucosal incision after sufficient submucosal injection. In this technique, the tip of the endoscope becomes stable within the pocket, which facilitates the subsequent submucosal dissection.…”

Enormous postoperative perforation after endoscopic submucosal dissection for duodenal cancer successfully treated with filling and shielding by polyglycolic acid sheets with fibrin glue and computed tomography-guided abscess puncture

“…The technique of endoscopic submucosal dissection (ESD) has recently been developed and accepted as a treatment for duodenal lesions as well as esophageal, gastric, and colorectal lesions [1,2]. However, the duodenum has an anatomically thin muscle wall and is a location in which endoscopic maneuvers and the maintenance of a stable endoscopic view are difficult.…”