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Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Aug 7, 2016; 22(29): 6595-6609
Published online Aug 7, 2016. doi: 10.3748/wjg.v22.i29.6595
Management of a large mucosal defect after duodenal endoscopic resection
Shintaro Fujihara, Hirohito Mori, Hideki Kobara, Noriko Nishiyama, Tae Matsunaga, Maki Ayaki, Tatsuo Yachida, Tsutomu Masaki
Shintaro Fujihara, Hirohito Mori, Hideki Kobara, Noriko Nishiyama, Tae Matsunaga, Maki Ayaki, Tatsuo Yachida, Tsutomu Masaki, Departments of Gastroenterology and Neurology, Kagawa University Faculty of Medicine, Kagawa 761-0793, Japan
Author contributions: Fujihara S analyzed the literature and wrote the manuscript; Mori H, Kobara H, Nishiyama N, Matsunaga T, Ayaki M and Yachida T made substantial contributions to acquisition and interpretation of data; and Masaki T gave final approval of the version to be published.
Conflict-of-interest statement: The authors have no conflict of interest to report.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Shintaro Fujihara, MD, PhD, Department of Gastroenterology and Neurology, Kagawa University Faculty of Medicine, Graduate School of Medicine, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan. sannai@kms.ac.jp
Telephone: +81-87-8912156 Fax: +81-87-8912158
Received: March 25, 2016
Peer-review started: March 26, 2016
First decision: May 12, 2016
Revised: May 23, 2016
Accepted: June 15, 2016
Article in press: June 15, 2016
Published online: August 7, 2016
Processing time: 126 Days and 0.3 Hours
Abstract

Duodenal endoscopic resection is the most difficult type of endoscopic treatment in the gastrointestinal tract (GI) and is technically challenging because of anatomical specificities. In addition to these technical difficulties, this procedure is associated with a significantly higher rate of complication than endoscopic treatment in other parts of the GI tract. Postoperative delayed perforation and bleeding are hazardous complications, and emergency surgical intervention is sometimes required. Therefore, it is urgently necessary to establish a management protocol for preventing serious complications. For instance, the prophylactic closure of large mucosal defects after endoscopic resection may reduce the risk of hazardous complications. However, the size of mucosal defects after endoscopic submucosal dissection (ESD) is relatively large compared with the size after endoscopic mucosal resection, making it impossible to achieve complete closure using only conventional clips. The over-the-scope clip and polyglycolic acid sheets with fibrin gel make it possible to close large mucosal defects after duodenal ESD. In addition to the combination of laparoscopic surgery and endoscopic resection, endoscopic full-thickness resection holds therapeutic potential for difficult duodenal lesions and may overcome the disadvantages of endoscopic resection in the near future. This review aims to summarize the complications and closure techniques of large mucosal defects and to highlight some directions for management after duodenal endoscopic treatment.

Keywords: Endoscopic mucosal resection; Endoscopic submucosal dissection; Duodenum; Complication; Bleeding; Perforation; Over-the-scope clip; Clip; Closure; Endoscopic full-thickness resection

Core tip: The duodenum is the most difficult and risky location for endoscopic treatment in the gastrointestinal tract. The risk of delayed perforation and bleeding is unacceptably high, and it is urgently necessary to establish a management protocol to prevent these serious complications. Prophylactic closure of mucosal defects after endoscopic resection is already known to prevent post-procedure-related complications. Conventional clips are primarily used, although these make it difficult to close the mucosal defect completely. Over-the-scope clips and polyglycolic acid sheets can overcome the disadvantage of conventional clips, and laparoscopic-endoscopic cooperative surgery and endoscopic full-thickness resection hold therapeutic potential for duodenal endoscopic treatment without hazardous complications.