PMC3145349_01
(a) Endoscopic appearance revealed a 20-mm diameter submucosal tumor with a smooth surface in the third portion of the duodenum. (b) Preoperative endoscopic ultrasonography (12 MHz miniature probe). Arrowheads indicate that muscle layer was preserved beneath the tumor without an extramural component.
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fig1
A male patient in his 60s visited our hospital because he was diagnosed with a submucosal tumor (SMT) of the duodenum that had progressed in size during 3-month follow up. esophagogastroduodenoscopy revealed a 20-mm diameter SMT located in the third portion of the duodenum (Figure 1(a)). CT scan revealed hypervascular tumor existing in the third portion of duodenum (Figure 1(b)).
(a) Proximal jejunum was clamped using intestinal forceps to avoid distention of the distal bowel by the laparoscope. (b, c) Laparoscopic and endoscopic view. Transmitted light of both flexible endoscopy and laparoscopy could be seen through the duodenal wall. (d, e) Identification of the tumor location by poking the duodenal wall.
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fig2
The peritoneal cavity was explored laparoscopically, and the proximal jejunum was gently clamped (Figure 2(a)). Tokyo, Japan). The endoscope was then advanced into duodenum, and we confirmed the lesion located at the third portion of duodenum with transmitted light from flexible endoscopy (Figures 2(b) and 2(c)). Subsequently, we confirmed that the lesion existed in the posterior wall by picking the anterior wall of duodenum (Figures 2(d) and 2(e)). The lesion revealed protruding toward the lumen without an extramural component (Figure 2(f)). The lesion was elevated by injecting physiological saline with epinephrine into the submucosal layer in a standard fashion.
(a) Mucosal incision and following submucosal dissection was performed by flush knife. (b) The tumor was got well mobilized, when the incision was made almost circumferentially except for the anal side of the tumor. (c) The root of the lesion was grasped with an electric snare. (d) EUS was performed during grasping the lesion with an electric snare with 2-channel endoscope to confirm resectability. (e) Postresected ulcer.
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fig3
Ltd, Tokyo, Japan) (Figure 3(a)). When the incision was made almost circumferentially except for the anal side of the tumor (Figure 3(b)), the tumor became well mobilized and was found to be located mainly in the submucosal layer using concurrent EUS. Tokyo, Japan), which revealed that the muscle layer was not involved under the snare, and the tumor was successfully resected (Figures 3(c) and 3(d)). The specimen was isolated and delivered perorally, and an intraoperative frozen section confirmed a free vertical margin pathologically. At the conclusion of the procedure, the mucosal defect was carefully inspected and left opened, since no major submucosal vessels were observed (Figure 3(e)).
PMC3145349_02
(a) Macroscopic view. Resected tumor was 18*15*15 mm in diameter without injury of pseudocapsule. (b) HE staining revealed that spindle cells were proliferating in the submucosal layer. Mitosis was seen less than three cells/50 HPF. (c) The majority of the tumor cell was positive for immunostaining of KIT.
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fig4
 The tumor showed spindle cells that stained positive for KIT (CD117) (Figures 4(b) and 4(c)).