Digestive Endoscopy最新文献

Endoscopic resection is a treatment option for non-ampullary duodenal neuroendocrine tumors (DNETs) confined to the submucosa, without nodal or distant metastasis, and < 10 mm [1]. However, because the duodenal wall is thin and DNETs arise from the deep mucosa, endoscopic treatment carries risks of incomplete histopathological resection and adverse events (AEs)—notably perforation and bleeding [2]. Underwater endoscopic mucosal resection (UEMR) has recently been reported effective for superficial non-ampullary duodenal epithelial tumors (SNADETs) [3, 4]. Furthermore, Japanese prospective data indicate a favorable safety profile for UEMR in SNADETs [3]; in a multinational comparison, UEMR was associated with fewer AEs than conventional EMR (CEMR) [4]; and CEMR using a bipolar snare has been reported safe [5]. Accordingly, we considered UEMR with a bipolar snare a potentially effective, safety-oriented option for small non-ampullary DNETs. We present a 72-year-old man in whom an 8-mm submucosal DNET was resected by UEMR using a bipolar snare (Video S1). The lesion, on the inferior wall of the duodenal bulb, appeared subepithelial (Figure 1). Forceps biopsy showed a neuroendocrine tumor; endoscopic ultrasonography confirmed submucosal confinement, and computed tomography showed no nodal or distant metastasis. The procedure used a GIF-XZ1200 gastroscope and EVIS X1 system (Olympus, Tokyo, Japan). Resection was completed with a 13-mm bipolar snare (ZEMEX Bipolar Snare S, Zeon Medical Co. Ltd., Tokyo, Japan) and VIO 3 (ERBE Elektromedizin, Tübingen, Germany; Auto Cut mode, Effect 3). Procedure time was 3 min. There were no AEs, and histopathology showed a well-differentiated NET G1 (7 × 4 × 3 mm; pT1, Ly0, V1) with negative lateral and vertical margins (Figure 2). Subsequent distal gastrectomy revealed no residual tumor or nodal metastasis. Although DNET-specific UEMR data are limited, UEMR with a bipolar snare may be a safe and effective resection method for small non-ampullary DNETs, consistent with reports on duodenal adenomas (Video S1).

Mamoru Tokunaga: conceptualization; investigation; procedure; video editing; writing – original draft. Yoshiyasu Kitagawa: procedure; writing – review and editing; supervision. Takuto Suzuki: writing – review and editing; supervision. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work.

The authors have nothing to report.

We confirm that informed consent has been obtained from the patient for the publication of their information and imaging data.

The authors declare no conflicts of interest.

Endoscopic treatment of tracheoesophageal fistulas (TEFs) remains challenging. Conventional techniques, such as stenting, clips, macroclips, and fibrin glue, have shown limited success, with closure rates below 50%. Cardiac septal occluders have shown more promising results, with reported success rates of up to 77.7% [1]. Endoscopic submucosal dissection (ESD)–based flap closure has emerged as a novel approach, demonstrating > 80% success in limited case reports. Variations include (a) total fistulectomy before mechanical closure [2], (b) use of a traction line for flap manipulation [3], (c) closure with endoloop and clips [4], and (d) pedicle or free mucosal flap transplantation [5].

We treated a 38-year-old male with a history of type C esophageal atresia, early repaired surgically in infancy. His postoperative course had been complicated by esophageal stricture, managed with balloon dilatations. He was referred for evaluation of worsening cough and recurrent respiratory infections. A barium swallow revealed a short tracheobronchial fistula (Figure 1a). Under general anesthesia, we performed an ESD-based closure. Gastroscopy revealed a 5 mm fistula orifice at 20 cm from the dental arches, 2 cm above the esophago-esophageal anastomosis (Figure 1b). Following submucosal lifting with glycerol, a circumferential incision was made 1 cm from the fistula using a 1.5 mm dual knife. An apple-core-shaped flap was created, dissecting close to the muscularis propria, 5 mm from the fistula. Argon plasma coagulation was applied to ablate neoepithelium. The flap was grasped with an endoloop and secured with four clips to ensure healing, two Olympus EZ clips 7 mm and two Lockado 16 mm (Figure 2a,b). No contrast extravasation was observed postprocedure (Figure 2c, Video S1).

The patient showed rapid clinical improvement, with resolution of cough and aspiration. He received peri and postprocedural antibiotics for 5 days. A 6-week follow-up barium swallow showed no residual fistula (Figure 2d). He remained symptom-free during 2 years of follow-up.

All authors substantially contributed to the concept and the design of the work, drafting, reviewing, and finally approved the version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

The authors declare no conflicts of interest.

Endoscopic submucosal dissection (ESD) is a well-established technique for esophageal tumor removal. However, ESD remains challenging due to factors like thin submucosa, esophageal motility, and limited maneuverability. Additionally, a single endoscope cannot simultaneously perform the traction, prompting the development of novel traction techniques to reduce surgical risks and en-bloc resection rates [1-4]. In this case, we developed a new 4-point internal traction method (Video S1).

A 60-year-old man with superficial esophageal neoplasm underwent ESD. A dual knife was used to mark a 0.5-cm margin along the lesion's outer edge, followed by injection of a methylene blue hyaluronate sodium saline solution into the submucosa to lift the lesion. Mucosa and submucosa were dissected along markings. A rubber band was attached to the first endoclip, and a cotton thread was secured to the rubber band. The endoclip and cotton thread were fixed on the anal side of the lesion, with the other end of the cotton thread left outside to control the rubber band and subsequent endoclip placements. External traction with the rubber band allowed placement of the second endoclip across it, followed by securing the third and fourth endoclips. The rubber band retraction caused the lesion's edges to curl upwards and inwards, fully exposing the submucosa (Figure 1). With repeated submucosal injections, the lesion was completely dissected. The 3.2 × 2.8 × 0.3 cm lesion was entirely removed in about 35 min, and the patient experienced a favorable prognosis. The operation schematic is shown in Figure 2.

The 4-point traction method facilitates ESD, especially for larger lesions where conventional traction fails. Although more clips are used, procedure time is significantly reduced, improving safety and efficiency despite slightly higher material cost. The fixed elasticity of the rubber band makes this method ideal for lesions approximately 2–4 cm.

X.T.: conceptualization, methodology, writing – review and editing, supervision, project administration. J.X. and X.T.: data curation. J.X., Y.L., and X.T.: writing – original draft. Y.L.: visualization.

We confirm that informed consent has been obtained from the patient for the publication of their information and imaging data.

The authors declare no conflicts of interest.