Suitable closure for post-duodenal endoscopic resection taking medical costs into consideration

Figure 1 White light endoscopic image, magnifying narrow band image, closure method of Case 2 (conventional clip). A: White light magnified endoscopic images with an irregular microsurface pattern in the second portion; B: Magnifying narrow band imaging images with an irregular microvascular pattern indicated focal cancer; C: Ulcer floor closure with a detainment snare and conventional clips.

Figure 2 White light endoscopic image, magnifying narrow band image, resection method, closure method of case 6 (over-the-scope clip). A: An approximately 13-mm depressed lesion is observed in the posterior wall side of the slightly anal side of the major duodenal papilla in the descending portion of the duodenum; B: The magnifying narrow band image shows a clear boundary between the tumor and normal mucosa, and a mildly irregular surface structure of the tumor. The microvascular pattern (yellow arrows) shows expansion, winding, and caliber variation, which we evaluated as an inflammatory change caused by pancreatic juice and bile acid rather than malignant findings; C: After circumferential resection, en bloc resection was conducted by hybrid endoscopic submucosal dissection using a snare resection when two-thirds of the submucosal trimming was finished; D: As the artificial ulcer floor occupied half of the circumference and was close to the major duodenal papilla, closure in the minor axial direction toward the intestinal tract was attempted by grasping the mucosa in the anal and mouth sides with a twin Grasper^® (yellow arrows); E: Complete suture closure was performed in the minor axial direction using an over-the-scope clip (OTSC) (yellow arrows); F: The OTSC was not visible on the ulcer floor, which had recovered within the mucosa with chorioepithelium 6 mo later.

Figure 3 White right endoscopic image, muscular layer surface and longitudinal closure method of the artificial ulcer after resection in case 13 (over-the-scope clip). A: An approximately 20-mm irregularly protruding lesion is observed in the posterior wall side of the slightly anal side of the major duodenal papilla in the descending portion of the duodenum. Duodenal cancer was diagnosed based on the magnifying narrow band imaging results; B: The detached thin myenteric parts could be observed by applying only mild countertraction using the tip hood; C: The largest artificial ulcer floor is approximately 30 mm, occupying half of the circumference of the duodenal lumen. Bile juice directly flowed onto the artificial ulcer floor from the major duodenal papilla (green curved arrow). Reefing closure using an over-the-scope clip (OTSC) was conducted as rapidly as possible while cleaning the ulcer floor. Because closure using the OTSC in the minor axial direction was technically difficult, longitudinal reefing was used; however, no postoperative stenosis was observed (yellow arrows).