Digestive Endoscopy最新文献

A 74-year-old woman was admitted for endoscopic submucosal dissection (ESD) of a superficial non-ampullary duodenal epithelial tumor. Esophagogastroduodenoscopy revealed a 20-mm 0-IIc tumor in the second portion of the duodenum, 5-cm proximal to the major papilla (Figure 1a). Duodenal ESD achieved complete resection without perforation (Figure 1b). After resection, we attempted to suture the entire mucosal defect using an over-the-scope clip (OTSC; 100.31, Ovesco Endoscopy AG, Tübingen, Germany), grasping both sides of the remnant normal tissue with a Twin Grasper (200.44; Ovesco) (Video S1). However, incomplete traction during OTSC deployment resulted in accidental entrapment of the Twin Grasper (Figure 1c). The device could not be retracted into the channel. Therefore, the shaft was cut outside the endoscope with pliers and covered the remaining forceps with a 16-Fr nasogastric tube to prevent mucosal injury (Figure 1d).

The next day, a bipolar direct current (DC) cutter (remOVE system, Ovesco) was used to remove the device. The OTSC was divided into two fragments by applying direct current pulses at two opposing sites of the clip (Figure 2a,b). The fragments were safely retrieved from the duodenum using forceps (remOVE Grasper) and a distal attachment cap (remOVE SecureCap 12), included in the remOVE system. The remaining mucosal defect was closed with re-openable clips (Mantis Closure Device, M00521421, Boston Scientific, MA; SureClip eco, RO-CD26195, MC Medical, Tokyo, Japan) (Figure 2c). The patient was discharged on Day 8 after ESD without any further complications.

OTSC with a Twin Grasper is widely used for closure of large mucosal defects [1, 2]. However, if accidental entrapment occurs, retraction is almost impossible. Removal of OTSC with a bipolar cutting device has been reported to be effective and safe in several case series [3, 4]. This case demonstrates the effective and safe troubleshooting of Twin Grasper entrapment by OTSC, highlighting the utility of bipolar cutting devices.

Conceptualization: Yuya Miyake and Takaaki Yoshikawa. Investigation: Yuya Miyake. Methodology: Takaaki Yoshikawa. Resources: Takaaki Yoshikawa. Supervision: Takaaki Yoshikawa and Shujiro Yazumi. Visualization: Yuya Miyake. Writing – original draft: Yuya Miyake. Writing – review and editing: all authors.

The patient described in this case report provided informed consent for publication of the clinical information and images.

The authors declare no conflicts of interest.

Subepithelial lesions (SELs) arising from the colonic muscularis propria are uncommon but clinically significant. With advancements in therapeutic endoscopy, endoscopic resection has become the preferred treatment approach. The submucosal tunneling endoscopic technique has gained increasing adoption owing to its distinct advantages, including an expanded operative space and enhanced visualization [1-3]. We report a case of a descending colon SEL that was successfully managed using the submucosal tunneling technique with complete full-thickness muscular resection.

A 59-year-old male was incidentally found to have a SEL in the descending colon, measuring approximately 25 mm in diameter (Figure 1a). Endoscopic ultrasound revealed a hypoechoic lesion originating from the muscularis propria with partial extraluminal extension (Figure 1b). The patient underwent endoscopic resection with tunneling technique (Video S1). Following mucosal incision and submucosal tunnel creation, the whitish tumor was clearly visualized (Figure 2a,b). During the procedure, the tumor was found to be firmly adherent to the muscularis propria layer, with no clear plane for dissection, which necessitated full-thickness muscle resection to achieve complete removal. The resultant linear mucosal defect allowed for effective endoscopic closure (Figure 2c,d). The patient fasted for 24 h and was discharged 4 days postoperatively without complications. The pathological results confirmed a leiomyoma.

The tunneling technique is a novel approach for SELs originating from the muscularis propria [4]. However, its application in the colon is technically demanding due to the organ's thin-walled structure, tortuous lumen, vigorous peristalsis, and prominent mucosal folds. Full-thickness resection in this setting further complicates luminal insufflation, impairing surgical field exposure and increasing the difficulty of anatomical delineation and precise suturing. The integration of tunneling with full-thickness excision offers distinct advantages, including preserved luminal distension and mucosal integrity, thereby optimizing visualization and suturing efficacy. This case marks the first successful application of this technique for a descending colon SEL, potentially expanding therapeutic options for such lesions.

Longbin Huang: conceptualization, writing original draft. Silin Huang: design of the work, data curation and visualization. Suhuan Liao: supervision, writing and editing, project administration. Final approval of the version to be published.

The authors declare no conflicts of interest.

The EndoSheather (Piolax, Kanagawa, Japan) is a novel device-delivery system composed of a tapered inner catheter and a wide outer sheath [1]. It accommodates instruments up to 1.9 mm in diameter to enable stricture dilation and passage of large-cup biopsy forceps, thereby facilitating mapping biopsies and troubleshooting procedures such as migrated stent retrieval [2, 3]. We herein describe the integration of the EndoSheather into a salvage percutaneous transhepatic biliary drainage-guided rendezvous (PTBD-RV) technique.

A 70-year-old man with a history of sigmoid colon neuroendocrine tumor resection suffered recurrent cholangitis secondary to malignant hilar bile duct stenosis from liver metastases (Figure 1). Tumor invasion had led to disconnection of the right anterior (Ba), right posterior (Bp) and left hepatic ducts. Plastic stents were placed in each segment, including one inserted into Segment 2 (B2).

Two years later, cholangitis recurred in Segment 3 (B3). Following unsuccessful transpapillary guidewire access, a PTBD catheter was temporarily placed in B3 for urgent drainage due to severe cholangitis (Figure 1D). Transpapillary drainage was subsequently attempted using PTBD-RV (Figure 2, Video S1).

The guidewire from the PTBD route failed to traverse the stricture into the duodenum but reached B2. Another guidewire was introduced into B2 via the transpapillary route, and the EndoSheather was advanced over this wire across the stricture. Large-cup biopsy forceps (Radial Jaw 4; Boston Scientific, MA, USA) were delivered through the sheath and grasped the PTBD guidewire in B2. The guidewire was withdrawn through the sheath to establish transpapillary access to B3. The tapered inner catheter enabled stricture traversal, while the wide-lumen sheath facilitated forceps guidance. Plastic stents were successfully placed in B3, B2, Bp, and Ba, completing drainage of all four ducts.

PTBD-RV is considered a salvage option for failed endoscopic retrograde cholangiopancreatography [4]. This case demonstrates the utility of the EndoSheather for complex malignant biliary strictures and transpapillary drainage [5].

Tomoyuki Tanaka wrote the manuscript. Yasuhiro Kuraishi co-wrote and reviewed the manuscript. Takaya Oguchi supervised the endoscopy and reviewed the manuscript.

The authors declare no conflicts of interest.