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• W3017076708 abstract "Endoscopic submucosal dissection (ESD) was developed in Japan and is now widely used around the world.1Draganov P.V. Gotoda T. Chavalitdhamrong D. et al.Techniques of endoscopic submucosal dissection: application for the Western endoscopist?.Gastrointest Endosc. 2013; 78: 677-688Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 2Cai M.Y. Zhou P.H. Yao L.Q. Current status of endoscopic resection in China.Dig Endosc. 2012; 24: 166-171Crossref PubMed Scopus (10) Google Scholar, 3Daoud D.C. Suter N. Durand M. et al.Comparing outcomes for endoscopic submucosal dissection between Eastern and Western countries: a systematic review and meta-analysis.World J Gastroenterol. 2018; 24: 2518-2536Crossref PubMed Scopus (33) Google Scholar Compared with piecemeal EMR, ESD allows en bloc removal of GI tract lesions, decreasing the rate of postprocedural recurrence and allowing adequate histologic interpretation of the resected specimen.4Committee A.T. Maple J.T. Abu Dayyeh B.K. et al.Endoscopic submucosal dissection.Gastrointest Endosc. 2015; 81: 1311-1325Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar, 5Cao Y. Liao C. Tan A. et al.Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract.Endoscopy. 2009; 41: 751-757Crossref PubMed Scopus (322) Google Scholar, 6Fujiya M. Tanaka K. Dokoshi T. et al.Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection.Gastrointest Endosc. 2015; 81: 583-595Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar However, ESD remains a meticulous, time-consuming, labor-intensive, and difficult-to-learn technique.4Committee A.T. Maple J.T. Abu Dayyeh B.K. et al.Endoscopic submucosal dissection.Gastrointest Endosc. 2015; 81: 1311-1325Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar Numerous studies and meta-analyses have confirmed the clinical benefits of ESD for removal of gastric, esophageal, and colonic lesions.5Cao Y. Liao C. Tan A. et al.Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract.Endoscopy. 2009; 41: 751-757Crossref PubMed Scopus (322) Google Scholar,6Fujiya M. Tanaka K. Dokoshi T. et al.Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection.Gastrointest Endosc. 2015; 81: 583-595Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar However, the duodenum remains the most difficult place to perform ESD, and even the experts from well-established ESD centers in Japan remain cautious about performing duodenal ESD because of the exceptional technical difficulties and extremely high rates of adverse events: intraprocedural (13%-50%) and delayed (9%) perforations, bleeding (18%), and need for rescue emergency surgery (14%).7Jung J.H. Choi K.D. Ahn J.Y. et al.Endoscopic submucosal dissection for sessile, nonampullary duodenal adenomas.Endoscopy. 2013; 45: 133-135Crossref PubMed Scopus (102) Google Scholar, 8Perez-Cuadrado-Robles E. Queneherve L. Margos W. et al.ESD versus EMR in non-ampullary superficial duodenal tumors: a systematic review and meta-analysis.Endosc Int Open. 2018; 6: E998-1007Crossref PubMed Google Scholar, 9Perez-Cuadrado-Robles E. Queneherve L. Margos W. et al.Comparative analysis of ESD versus EMR in a large European series of non-ampullary superficial duodenal tumors.Endosc Int Open. 2018; 6: E1008-E1014Crossref Google Scholar, 10Saito Y. Nonaka S. ESD as first-intent resection method: also for the duodenum?.Endosc Int Open. 2019; 7: E1761-E1762Crossref Google Scholar, 11Kakushima N, Yoshida M, Yabuuchi Y, et al. Present status of endoscopic submucosal dissection for non-ampullary duodenal epithelial tumors. Clin Endosc. Epub 2020 Jan 15.Google Scholar, 12Yahagi N. Kato M. Ochiai Y. et al.Outcomes of endoscopic resection for superficial duodenal epithelial neoplasia.Gastrointest Endosc. 2018; 88: 676-682Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 13Kato M. Sasaki M. Mizutani M. et al.Predictors of technical difficulty with duodenal ESD.Endosc Int Open. 2019; 7: E1755-E1760Crossref Google Scholar If duodenal ESD is so difficult and dangerous, should we stop doing it? Professor Yahagi and his colleagues12Yahagi N. Kato M. Ochiai Y. et al.Outcomes of endoscopic resection for superficial duodenal epithelial neoplasia.Gastrointest Endosc. 2018; 88: 676-682Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar attempted to answer this question by reviewing the various aspects of duodenal ESD in a series of 3 retrospective studies: the first study compared 174 consecutive duodenal ESDs with 146 consecutive duodenal EMRs performed from June 2010 to June 2017. This study demonstrated the advantages of ESD for en bloc resection of large duodenal tumors, especially lesions with suspected malignancy and those that are not amenable to EMR because of such factors as difficult location and poor lifting with submucosal fluid injection.12Yahagi N. Kato M. Ochiai Y. et al.Outcomes of endoscopic resection for superficial duodenal epithelial neoplasia.Gastrointest Endosc. 2018; 88: 676-682Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar However, ESD was associated with a higher rate of perforation (15.5%),12Yahagi N. Kato M. Ochiai Y. et al.Outcomes of endoscopic resection for superficial duodenal epithelial neoplasia.Gastrointest Endosc. 2018; 88: 676-682Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar and the subsequent second publication specifically addressed predictors of technical difficulties and perforations during duodenal ESD.13Kato M. Sasaki M. Mizutani M. et al.Predictors of technical difficulty with duodenal ESD.Endosc Int Open. 2019; 7: E1755-E1760Crossref Google Scholar Finally, the third study, published in the current issue of Gastrointestinal Endoscopy, concentrates exclusively on the management of perforations during duodenal ESD.14Fukuhara S. Kato M. Iwasaki E. et al.Management of perforation related to endoscopic submucosal dissection for superficial duodenal epithelial tumors.Gastrointest Endosc. 2020; 91: 1129-1137Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar The authors added an additional 90 procedures and analyzed a total of 264 consecutive duodenal ESDs performed in the same institution from June 2010 to December 2018.14Fukuhara S. Kato M. Iwasaki E. et al.Management of perforation related to endoscopic submucosal dissection for superficial duodenal epithelial tumors.Gastrointest Endosc. 2020; 91: 1129-1137Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar This study presented very impressive final results. Although the duodenal lesions were large (mean tumor size, 29.8 ± 17.6 mm), and 34.5% had adenocarcinoma, an R0 resection rate was achieved in 83.0% of patients, with a combined perforation rate of 13.6% (intraprocedural perforations in 32 patients [12.1%] and delayed perforations in 4 patients [1.5%]).14Fukuhara S. Kato M. Iwasaki E. et al.Management of perforation related to endoscopic submucosal dissection for superficial duodenal epithelial tumors.Gastrointest Endosc. 2020; 91: 1129-1137Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar We can learn several important lessons from this study. First, duodenal ESD, even in the most experienced hands, remains a technically difficult and dangerous procedure: an initial 174 duodenal ESDs were done by 6 very experienced endoscopists who had performed over 1000 ESD procedures by the start of this study.13Kato M. Sasaki M. Mizutani M. et al.Predictors of technical difficulty with duodenal ESD.Endosc Int Open. 2019; 7: E1755-E1760Crossref Google Scholar Despite such extensive ESD experience, 27 perforations occurred in the first 174 cases.12Yahagi N. Kato M. Ochiai Y. et al.Outcomes of endoscopic resection for superficial duodenal epithelial neoplasia.Gastrointest Endosc. 2018; 88: 676-682Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar A comparison of the latest study (36 perforations in 264 patients, 13.6%) with the 2 previous studies demonstrates that growing experience in duodenal ESD decreased the rate of perforation from 17.0% (first 88 patients) to 15.9% (second 88 patients) and, finally, to 8.0% (7 perforations in the last 88 enrolled patients).14Fukuhara S. Kato M. Iwasaki E. et al.Management of perforation related to endoscopic submucosal dissection for superficial duodenal epithelial tumors.Gastrointest Endosc. 2020; 91: 1129-1137Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar This final rate of perforation is much lower than the previously reported rate of perforations associated with duodenal ESD (21.4%-50.0%),11Kakushima N, Yoshida M, Yabuuchi Y, et al. Present status of endoscopic submucosal dissection for non-ampullary duodenal epithelial tumors. Clin Endosc. Epub 2020 Jan 15.Google Scholar,12Yahagi N. Kato M. Ochiai Y. et al.Outcomes of endoscopic resection for superficial duodenal epithelial neoplasia.Gastrointest Endosc. 2018; 88: 676-682Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar and it is approaching the reported perforation rate during colonic ESD (4.1%-11.6%).6Fujiya M. Tanaka K. Dokoshi T. et al.Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection.Gastrointest Endosc. 2015; 81: 583-595Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar,15Hong S.N. Byeon J.S. Lee B.I. et al.Prediction model and risk score for perforation in patients undergoing colorectal endoscopic submucosal dissection.Gastrointest Endosc. 2016; 84: 98-108Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar The second lesson from the current study is related to management of duodenal perforations: complete closure of intraprocedural perforations with through-the-scope endoscopic clips or a combination of endoscopic clips and a string (string clip suturing technique)16Yahagi N. Nishizawa T. Akimoto T. et al.New endoscopic suturing method: string clip suturing method.Gastrointest Endosc. 2016; 84: 1064-1065Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar was achieved in only 13 patients (40.6%).14Fukuhara S. Kato M. Iwasaki E. et al.Management of perforation related to endoscopic submucosal dissection for superficial duodenal epithelial tumors.Gastrointest Endosc. 2020; 91: 1129-1137Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Although over-the-scope endoscopic clips are available in Japan, these devices cannot close large mucosal defects and perforations >3 cm. Unfortunately, the Overstitch endoscopic suturing device (Apollo Endosurgery, Austin, Tex, USA) is not currently commercially available in Japan and was not used in this study. The Overstitch endoscopic suturing system allows the creation of separate stitches or a continuous suturing line of various lengths, and it could be an ideal rescue device for closure of duodenal perforations and large mucosal defects after ESD (Video 1, available online at www.giejournal.org).17Kantsevoy S.V. Bitner M. Mitrakov A.A. et al.Endoscopic suturing closure of large mucosal defects after endoscopic submucosal dissection is technically feasible, fast, and eliminates the need for hospitalization (with videos).Gastrointest Endosc. 2013; 79: 503-507Abstract Full Text Full Text PDF Scopus (142) Google Scholar, 18Kantsevoy S.V. Bitner M. Davis J.M. et al.Endoscopic suturing closure of large iatrogenic colonic perforation.Gastrointest Endosc. 2015; 82: 754-755Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 19Kantsevoy S.V. Bitner M. Hajiyeva G. et al.Endoscopic management of colonic perforations: clips versus suturing closure (with videos).Gastrointest Endosc. 2016; 84: 487-493Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar The third lesson from this study addresses the utility of endoscopic retrograde cholangiopancreatography (ERCP) with placement of nasobiliary and nasopancreatic drains to protect the site of duodenal perforation from the damaging effect of bile and pancreatic juice.14Fukuhara S. Kato M. Iwasaki E. et al.Management of perforation related to endoscopic submucosal dissection for superficial duodenal epithelial tumors.Gastrointest Endosc. 2020; 91: 1129-1137Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Placement of nasobiliary and nasopancreatic drains was especially important for lesions in the descending part of the duodenum near the papilla of Vater. In conclusion, the study by Fukuhara et al14Fukuhara S. Kato M. Iwasaki E. et al.Management of perforation related to endoscopic submucosal dissection for superficial duodenal epithelial tumors.Gastrointest Endosc. 2020; 91: 1129-1137Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar represents the largest single-center experience in duodenal ESD in the world and demonstrates that in specialized high-volume centers, the perforation rate during duodenal ESD becomes comparable with perforations during colonic ESD. Because of the high rate of intraprocedural perforations, only endoscopists who have performed a very large number of ESDs should attempt duodenal ESD. Centers specializing in duodenal ESD should also have expertise in the use of the Overstitch endoscopic suturing device and ERCP with the placement of nasobiliary and nasopancreatic drains for successful management of perforations during and after duodenal ESD. Dr Kantsevoy is a co-founder of, shareholder in, and consultant for Apollo Endosurgery; a co-founder of, holder of equity in, and consultant for Endocages; an advisory board member, holder of equity in, and consultant for LumenDi; a participant in active litigation involving LumenR; a consultant for Medrobotics, Medtronic, and Olympus; a holder of equity in Slater Endoscopy; and a holder of equity in and a consultant for Vizballoon. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIwOThhNDI1NGU1ZGRhOWZlNjIwMGYxNzcwNmI1MmEzZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4MTAxMTU4fQ.BXB2P0DVvsWneM56jisqLrD9LcVAMe1coXyV4uxeZy-HFyK9cupSWqBSK4UZ8kv53bEW5otRv8APd02X_EhXcMAypWZPSMJhN4YXqVKWgIwBfQb2Ub6_S3AhSOhuSMnTM33pFgFRdk0nl3ugXBwyAKZOcxtdG47bhBw4d9MNSdcscFdY1FEY2fl7yq4rE0sX-lN1hPRJkHu3K4oMhjcGUdh3sdHwIPEZTTPB66G3SikExGUjRRw568gyt1Ad-7tf1k4qQhNY87r2YSlx90EVID2Brpq5jvhYKwnUk9XRxppzQkcMC4GwqvHaaasW3Af_n1glqyozwpBoED8Iv0a0yA Download .mp4 (50.73 MB) Help with .mp4 files Video 1Endoscopic suturing closure of a large perforation during duodenal endoscopic submucosal dissection (ESD) A Flat sessile polyp is located in the descending part of the duodenum. Hespan solution with indigo carmine is injected into the submucosal space under the polyp to lift the lesion. Endoscopic submucosal dissection is performed with a DualKnife (Olympus America, Center Valley, Pa, USA), and the polyp is resected en bloc. The specimen is aspirated into the distal attachment (Olympus America) mounted on the distal end of the endoscope and removed. The endoscope is re-inserted into the duodenum, and a large full-thickness perforation is clearly seen at the site of ESD. Bleeding from the edge of the perforation is stopped with a Coagrasper (Olympus America). Then the perforation is completely closed with 1 continuous suture by use of the Overstitch endoscopic suturing device (Apollo Endosurgery, Austin, Tex, USA). Management of perforation related to endoscopic submucosal dissection for superficial duodenal epithelial tumorsGastrointestinal EndoscopyVol. 91Issue 5PreviewEndoscopic submucosal dissection (ESD) is being performed more frequently as a local treatment for superficial duodenal epithelial tumors (SDETs). However, ESD for SDETs is technically difficult because of specific anatomic features that increase the risk of perforation and often require surgery. This study was performed to evaluate the management of ESD-related perforation in patients with SDETs. Full-Text PDF" @default.
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• W3017076708 title "Duodenal endoscopic submucosal dissection: Is it ready for primetime? (with video)" @default.
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