VideoGIE
Endoscopic submucosal dissection of a duodenal neuroendocrine tumor
Figure 1. A, Visualization of the submucosal lesion in the distal, anterior wall of the duodenal bulb. B, A submucosal injection was performed using dilute indigo carmine, dilute adrenaline, and succinylated gelatin, followed by a circumferential mucosal incision. C, Endoscopic submucosal dissection was performed. D, The lesion was completely excised en bloc, leaving a clear mucosal defect.
A 64-year-old woman was found to have an incidental 10-mm sessile (Paris 0-Is) submucosal lesion in the duodenal bulb, subsequently shown to be a neuroendocrine tumor on biopsy. EUS confirmed a 10 mm 10 mm solid lesion in the submucosa without muscularis propria involvement. Octreotide positron emission tomography/CT scan showed local disease only. Endoscopic submucosal dissection (ESD) was performed with a Dual Knife (Olympus Medical Systems, Tokyo, Japan) using dilute indigo carmine, adrenaline (1:100,000), and succinylated gelatin (Gelofusine; B. Braun, Crissier, Switzerland) injection, and the lesion was completely excised en bloc (Fig. 1; Video 1, available online at www.giejournal.org). Histopathology confirmed a well-differentiated carcinoid tumor confined to the submucosa, with negative lateral and deep margins. ESD is an established technique for the complete (R0) en bloc resection of early mucosal GI neoplasms. However,
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
ESD of duodenal lesions is more technically challenging and is associated with a high rate of bleeding and perforation. Endoscopic resection of localized carcinoid tumors !1 cm is recommended as a potentially curative procedure. It is likely to be safer in the duodenal bulb because of the absence of mucosal folds and the relatively thicker muscle layer; however, the en face approach in this case requires extra care. This case illustrates the technique of ESD for R0 resection of localized duodenal carcinoid tumors. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Crispin Musumba, MRCP, Rebecca Sonson, RN, Nicholas Tutticci, FRACP, Kavinderjit Nanda, MRCP, Michael J. Bourke, FRACP, Department of Gastroenterology, Westmead Hospital, Westmead, New South Wales, Australia
http://dx.doi.org/10.1016/j.gie.2013.11.011
Endoscopic resection of an ampullary gangliocytic paranganglioma A 48-year-old man was referred for endoscopic evaluation of an incidentally detected subepithelial duodenal tumor. EUS evaluation demonstrated a hypoechoic, wellcircumscribed 1.5-cm lesion confined to the submucosal
layer and not involving the muscularis propria. En bloc endoscopic resection was performed. Histopathology of the resected specimen demonstrated a gangliocytic paraganglioma, a rare submucosal tumor most commonly
716 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5 : 2014
www.giejournal.org
Endoscopic submucosal dissection of a duodenal neuroendocrine tumor
Figure 1. A, Visualization of the submucosal lesion in the distal, anterior wall of the duodenal bulb. B, A submucosal injection was performed using dilute indigo carmine, dilute adrenaline, and succinylated gelatin, followed by a circumferential mucosal incision. C, Endoscopic submucosal dissection was performed. D, The lesion was completely excised en bloc, leaving a clear mucosal defect.
A 64-year-old woman was found to have an incidental 10-mm sessile (Paris 0-Is) submucosal lesion in the duodenal bulb, subsequently shown to be a neuroendocrine tumor on biopsy. EUS confirmed a 10 mm 10 mm solid lesion in the submucosa without muscularis propria involvement. Octreotide positron emission tomography/CT scan showed local disease only. Endoscopic submucosal dissection (ESD) was performed with a Dual Knife (Olympus Medical Systems, Tokyo, Japan) using dilute indigo carmine, adrenaline (1:100,000), and succinylated gelatin (Gelofusine; B. Braun, Crissier, Switzerland) injection, and the lesion was completely excised en bloc (Fig. 1; Video 1, available online at www.giejournal.org). Histopathology confirmed a well-differentiated carcinoid tumor confined to the submucosa, with negative lateral and deep margins. ESD is an established technique for the complete (R0) en bloc resection of early mucosal GI neoplasms. However,
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
ESD of duodenal lesions is more technically challenging and is associated with a high rate of bleeding and perforation. Endoscopic resection of localized carcinoid tumors !1 cm is recommended as a potentially curative procedure. It is likely to be safer in the duodenal bulb because of the absence of mucosal folds and the relatively thicker muscle layer; however, the en face approach in this case requires extra care. This case illustrates the technique of ESD for R0 resection of localized duodenal carcinoid tumors. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Crispin Musumba, MRCP, Rebecca Sonson, RN, Nicholas Tutticci, FRACP, Kavinderjit Nanda, MRCP, Michael J. Bourke, FRACP, Department of Gastroenterology, Westmead Hospital, Westmead, New South Wales, Australia
http://dx.doi.org/10.1016/j.gie.2013.11.011
Endoscopic resection of an ampullary gangliocytic paranganglioma A 48-year-old man was referred for endoscopic evaluation of an incidentally detected subepithelial duodenal tumor. EUS evaluation demonstrated a hypoechoic, wellcircumscribed 1.5-cm lesion confined to the submucosal
layer and not involving the muscularis propria. En bloc endoscopic resection was performed. Histopathology of the resected specimen demonstrated a gangliocytic paraganglioma, a rare submucosal tumor most commonly
716 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5 : 2014
www.giejournal.org
