PMC5140861_01
Endoscopic findings of duodenal tumor. a: Conventional endoscopy. A reddened, sessile, elevated lesion measuring approximately 30 mm in diameter was observed in the anterior wall of the duodenal bulb, and an area of whitish lower elevation extended around the lesion. b: Magnifying endoscopy with narrow-band imaging. Leaf-like villous structures of various sizes were observed in the elevated area. c: Magnifying endoscopy with narrow-band imaging combined with water-immersion technique. The widths of the villi were wider than those in the surrounding normal area. d: Chromoendoscopy. Spraying of indigo carmine clearly showed the border of the lesion and the unevenness of its surface.
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On upper gastrointestinal endoscopy performed at our hospital, a reddened, sessile, elevated lesion measuring approximately 30 mm in diameter was detected in the anterior wall of the duodenal bulb, and a whitish lower elevated area spread around the lesion (Fig. 2a). TYPE H260Z, Olympus, Tokyo, Japan) revealed leaf-like villous structures of various sizes. The widths of the villi were greater than those in the surrounding normal areas (Fig. 2b and c). Chromoendoscopy with indigo carmine clearly showed the border of the lesion and the unevenness of its surface (Fig. 2d).
Duodenal ESD and endoscopic closure of gastrointestinal perforation with the OTSC system. a: Although a mixture of glyceol and hyaluronic acid was locally injected into the submucosal layer, the elevation of the lesion was poor, and submucosal dissection was difficult. b: Resection of the lesion by snaring with a circumferential incision resulted in a full-thickness perforation measuring approximately 18 mm in diameter and arterial bleeding from the full thickness resection site. c: The applicator cap with a mounted OTSC clip was attached to the tip of the endoscope. d: The left edge of the perforation was grasped with one jaw of the OTSC Twin Grasper. e: The other jaw of the OTSC Twin Grasper was opened to grasp the right edge of the perforation while grasping the left edge with one jaw. f: The grasped tissue was pulled into the applicator cap, with continuous suctioning. g: The gastrointestinal perforation was endoscopically closed with the OTSC system.
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Although a mixture of glyceol and hyaluronic acid was locally injected into the submucosa, the elevation of the lesion was insufficient, and submucosal dissection was difficult (Fig. 3a). Since a small perforation was noted during submucosal dissection, the procedure was changed to snaring with circumferential incision, which caused a full-thickness perforation measuring approximately 18 mm in diameter (Fig. 3b). After being attached to an 11/6t OTSC system (Fig. 3c), it was then re-inserted. Twin Grasper, which can be opened separately, in positions of correct approximation (Fig. 3d and e). The grasped tissue was pulled into the applicator cap, and the OTSC clip was then deployed while also performing continuous suction (Fig. 3f and g, Supplementary material).
Gastrografin swallow seven days after OTSC clip placement. The OTSC clip was placed in the anterior wall of the duodenal bulb. Gastrografin passed to the anal side. No leakage was observed.
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Seven days after the procedure, the absence of leakage was confirmed by a gastrografin swallow (Fig. 4).
Follow-up upper gastrointestinal endoscopy. a: Upper gastrointestinal endoscopy one month after the OTSC clip placement. The perforation was closed with the OTSC clip. b: Upper gastrointestinal endoscopy one year later. The OTSC clip was disengaged, and the resection site was scarred.
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On follow-up upper gastrointestinal endoscopy performed one month later, the perforation was closed by the OTSC clip (Fig. 5a), and the endoscope could be advanced to the anal side. Upper gastrointestinal endoscopy performed one year later showed disengagement of the OTSC clip and scarring of the resection site (Fig. 5b).