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Duodenal endoscopic submucosal dissection is a high-risk technique; however, prophylactic closure of mucosal defects reduces the risk. Unfortunately, we have encountered cases where closure is difficult, especially in large lesions. Therefore, we developed a novel closure technique, a string clip suturing method with an anchor. This study aimed to elucidate the feasibility of this method. Five patients underwent this method for the closure of mucosal defects after duodenal endoscopic submucosal dissection. The initial string clip was deployed at the anal end of the mucosal defects and the second clip was deployed at the other end of the mucosal defect. A third clip was deployed on the muscular layer in the middle of the mucosal defect. The free end of the string was pulled, and additional clips were deployed around the first to the third clips for complete closure. Because of grasping the muscle layer, string clip suturing method with an anchor can be employed for secure closure without creating a pocket. We reviewed the background and clinical course of hospitalization of patients who underwent this method. The resected specimens ranged from 52-103 mm in diameter. Complete closure of the mucosal defects was possible in all the cases. There were no adverse events, and no cases required additional treatment. All the patients were discharged within seven days. The new method achieved secure closure even for large mucosal defects after duodenal endoscopic submucosal dissection. This is a technique that can be applied to other organs, e.g., the colon.

Background and study aims In esophageal endoscopic submucosal dissection (ESD), the effectiveness of traction including clip-thread method has been reported, but it is difficult to adjust the direction of traction. Therefore, we developed a dedicated over-tube type traction device (ENDOTORNADO) that has a working channel and allows traction from any directions by rotating itself. We investigated the clinical feasibility and potential usefulness of this new device in esophageal ESD. Patients and methods This was a single-center, retrospective study. Six cases of esophageal ESD with ENDOTORNADO from January to March 2022 (tESD group) were compared with 23 cases of conventional esophageal ESD performed by the same operator from January 2019 to December 2021 (cESD group) in terms of clinical treatment outcomes. Results In all cases, en bloc resection was achieved without intraoperative perforation. The total procedure speed was significantly increased in tESD group (23 vs. 30 mm2/min, P = 0.046). In particular, the submucosal dissection time was significantly reduced to about one-quarter in tESD group (11 vs. 42 min, P = 0.004). Conclusions ENDOTORNADO creates the adjustable traction from any directions and may have the clinical feasibility. It would be an option for human esophageal ESD.

Background and study aims Colorectal endoscopic submucosal dissection (ESD) of diverticulum-associated lesions is challenging because these lesions require precise excision in narrow spaces. The water pressure method (WPM) uses active water pressure by the waterjet function under saline solution-filled conditions. This study aimed to determine the feasibility of WPM for resection of diverticulum-associated lesions. Patients and methods This was a retrospective, observational case series study. We reviewed diverticulum-associated lesions treated by ESD with WPM at our institution between June 2017 and July 2021. Diverticulum-associated lesions were classified as follows: type 1, lesions in contact with or within 3 mm of the edge of a diverticulum; type 2, lesions that partially infiltrated the interior of a diverticulum; and type 3, lesions that infiltrated the interior of and completely covered the diverticulum. We collected data on the clinical characteristics and outcomes of the lesions. Results Seven diverticulum-associated lesions were treated with ESD using WPM. The median lesion size was 37 mm (interquartile range: 25–54 mm). There were three cases of type 1, three cases of type 2, and one case of type 3. Three lesions were resected circumventing the diverticulum, and four lesions involved resection of the diverticulum. The en bloc resection and R0 resection rates were 86 %. One patient had severe fibrosis, which caused perforation, and in another patient, the diverticulum was too deep and narrow to be completely isolated. Conclusions WPM allowed for precise procedures in the diverticulum. The feasibility of WPM has been suggested for diverticulum-associated lesions, although cases have been complex.

Although lesions occupying a large circumference are associated with the risk of post-ESD strictures, the corresponding data for duodenal lesions are unknown. We aimed to analyze the incidence of post-ESD strictures after wide-field duodenal ESD.In this retrospective study of duodenal lesions treated with ESD, between July 2010 and August 2021, we included lesions that resulted in mucosal defects occupying more than half of the circumference and excluded lesions located in bulbs and involving Vater's papilla. We analyzed the incidence rates of stricture and luminal narrowing, in addition to bleeding and perforation as the outcomes in this study. Stricture was defined as the inability of the endoscope to pass through the lumen. A single endoscopist reviewed all endoscopic images and judged the degree of luminal narrowing RESULTS: A total of 80 lesions were included, of which two involved mucosal defects occupying more than 90% of the circumference. The wound was closed, at least partially, in 90% in all lesions, and in 86% of lesions with mucosal defect occupying more than 75% of the circumference. None of the lesions caused delayed perforation and stricture, whereas two lesions caused delayed bleeding. Only six lesions caused luminal narrowing. When examined by the degree of closure, the rate of luminal narrowing increased with complete closure, incomplete closure, and un-closure (4.9%, 9.1%, and 25.0%, respectively).Suturing may prevent post-ESD bleeding and perforation, as well as stricture formation in cases of duodenal tumors, with mucosal defects occupying a large circumference.

Video Video 1 Esophageal endoscopic submucosal dissection on post–endoscopic variceal ligation scars with injection under red dichromatic imaging.

Bleeding and hematoma formation during submucosal injection in esophageal endoscopic submucosal dissection (ESD) reduce the visibility of the submucosa. Red dichromatic imaging (RDI) is an endoscopic technique that provides better visualization of the deep submucosal blood vessels. We speculated that blood vessel injury could be avoided with RDI. This pilot study evaluated the role of RDI in preventing bleeding and hematoma formation during esophageal ESD.This was a single-center retrospective observational study. We examined 60 patients who underwent ESD with white light imaging (WLI) and RDI. A single endoscopist reviewed all of the surgical videos to document the incidence and severity of bleeding episodes. Eighteen videos provided adequate quality and detail, and the number of blood vessels traversing the mucosal incision lines of the lesions in these videos was evaluated under WLI and RDI.The WLI group had a significantly higher incidence of hematomas per unit area compared to the RDI group (0.18/cmRDI reduced the incidence of bleeding and hematoma formation during submucosal injection in esophageal ESD. It was assumed that the improvement of blood vessel visibility by RDI might have contributed to the result.

A standard treatment method for pedunculated duodenal lesions has not yet been established. This study aimed to evaluate the feasibility of endoscopic resection (ER) for pedunculated duodenal lesions, especially for large lesions.This study retrospectively reviewed cases of pedunculated duodenal lesions treated with ER at our institute between July 2010 and January 2021. We collected data on the clinical characteristics and treatment outcomes. In addition, the cases were divided based on the treatment provided for the lesion, i.e., the ESD and snare resection groups, and we compared the data between the two groups.Thirty-eight cases were included in this study. The overall en bloc resection rate was 95%. No perforation occurred in any of the cases. There were 10 cases treated with ESD, which were considered difficult to achieve en bloc resection using snare forceps, and 28 cases treated with snare resection. Although the median lesion size was significantly larger in the ESD group than in the snare resection group (27 [range 23-66] vs. 19 [range 6-55] mm, P = 0.0052), treatment outcomes were not significantly different between the two groups. Among the 10 cases treated using ESD, en bloc resection was achieved in all cases, along with specimen retrieval without any perforations, despite the large size of the lesions.ER could be performed to achieve a high en bloc resection rate without any perforations in pedunculated duodenal lesions, even in extremely large (e.g., ≧ 60 mm) lesions, suggesting that ER is feasible and may be an alternative to surgical resection for large pedunculated duodenal lesions.