Tip-in gel immersion endoscopic mucosal resection with partial submucosal injection for a superficial nonampullary duodenal epithelial tumor on the duodenal angulus

Abstract

Superficial nonampullary duodenal epithelial tumors (SNADETs) located on the inner side of the duodenal angulus are challenging to visualize and snare due to the intestinal flexure.¹ Here, we report a case where gel immersion endoscopic mucosal resection (EMR), supplemented with partial submucosal injection (PI) on the lesion's anal side only for better lesion visualization,¹ and tip-in EMR,¹ which is the snare tip is inserted into the submucosa and fixed, appeared beneficial for a SNADET located on the duodenal angulus (Figs 1,2; Video S1).

The patient was a 44-year-old woman with a 20 mm flat elevated lesion with the protruded component on the lesion's anal side located on the inner side of the inferior duodenal angulus. The visibility of the lesion's anal border was obscured by its protruded component and location, making it difficult to fix the snare tip position with underwater EMR. Thus, after filling the duodenum with a gel product (VISCOCLEAR; Otsuka Pharmaceuticals Factory, Tokyo, Japan), 8 mL of 0.4% sodium hyaluronate (MucoUp; Boston Scientific, Tokyo, Japan) with indigo carmine was partially injected on the lesion's anal side only, and the snare (SD-16U-1; Olympus, Tokyo, Japan) was deployed at the tip and fixed in the submucosa by tip-in at the same site. In this state, by pulling out the scope while opening the snare, and then strangulating, the lesion was resected en bloc using an electrosurgical unit (VIO300D; ERBE Electromedizin, Tuebingen, Germany; settings Endocut Q: effect, 2; duration, 2; interval, 2; forced coagulation, effect, 2; power, 20 W) without shifting the snare tip.

Although other resection methods may be considered for laterally spreading SNADETs much larger than 20 mm,³ the combination of PI and the tip-in technique may enable simpler and more effective endoscopic resection, even for relatively large SNADETs (~20 mm) with poor visibility located on the inner side of the duodenal angulus.

Authors declare no conflict of interest for this article.