Abstract
Endoscopic submucosal dissection (ESD) for pyloric neoplasms extending into the duodenum is technically challenging. In this video, we present how the use of a novel slim therapeutic endoscope facilitated ESD of a circumferential lesion extending across the pylorus and into the duodenal bulb.
ESD for a circumferential pyloric neoplasm extending into the duodenum was performed (Figure 1). Completion of the ESD across the pyloric ring and in retroflexion in the duodenal bulb was achieved using a novel therapeutic slim gastroscope (distal tip diameter of 7.9 mm and 3.2 mm working channel). Following ESD, the circumferential mucosal defect was approximated with endoscopic suturing.
This is the case of a 78-year-old man with a remote history of early gastric cancer in the pre-pyloric region treated with curative endoscopic resection and subsequently with multiple sessions of endoscopic radiofrequency ablation for recurrent adenoma at the pylorus. The patient was referred to our institution for endoscopic management given the recalcitrant biopsy-proven adenoma with high-grade dysplasia (HGD) with associated pyloric stenosis. Endoscopic ultrasound (EUS) and computed tomography (CT) were negative for invasive or distant disease. ESD with en-bloc resection of the circumferential pyloric neoplasm extending into the duodenum was achieved using the therapeutic slim gastroscope followed by circumferential pyloric mucosal defect closure with over-the-scope suturing. Final pathology was consistent with complete (R0) resection of an adenoma with HGD. The patient underwent 3 dilation sessions within a 6-week period of the ESD for stricture resolution. The patient did well without evidence of recurrence on histopathology up to 6 months following the ESD.
In conclusion, extensive ESD at the pylorus is a technically challenging procedure. The use of the novel therapeutic thin gastroscope may enhance the successful and safe ESD of lesions in anatomically complex regions characterized by luminal narrowing and steep angulations. Endoscopic suturing of circumferential mucosal defects around the pylorus is feasible and may reduce the risk of delayed adverse events.