Management of a large mucosal defect after duodenal endoscopic resection

Figure 1 Schema of endoscopic closure with through-the-scope-clips and over-the scope-clip. TTSC: Through-the-scope-clips; OTSC: Over-the scope-clip.

Figure 2 Immediate perforation after duodenal endoscopic mucosal resection with circumferential mucosal incision. A: An adenoma, 20 mm in size with an ulcer scar, was located in the inferior wall of the duodenal bulb; B: After duodenal EMR, immediate perforation occurred; C, D: The perforation was closed using multiple hemoclips. EMR: Endoscopic mucosal resection.

Figure 3 Delayed bleeding after duodenal endoscopic submucosal dissection. A: An adenoma, 20 mm in size, was located in the posterior wall of the second part of the duodenum; B: Prophylactic closure with a hemoclip was performed after ESD; C: The patient complained of melena at post-ESD day 13, and esophagoduodenoscopy revealed bleeding at the base of the ulcer because several clips had fallen off; D: The large mucosal defect was closed with multiple clips and Endoloops. ESD: Endoscopic submucosal dissection.

Figure 4 Prophylactic closure after duodenal endoscopic mucosal resection. A: Chromoendoscopy with indigo carmine was performed before endoscopic resection; B: A small-sized mucosal defect was detected; C, D: Prophylactic closure was performed with a hemoclip.

Figure 5 Diagram of a closure technique with the additional use of a loop clip, 8-ring loop, and small incision around the mucosal defect using a needle-type knife.

Figure 6 Diagram of a closure technique with the additional use of endoloop and a ring-shaped thread.

Figure 7 Methods for endoscopic sliding closure after endoscopic submucosal dissection. A: A mucosal defect was identified after ESD; B, C: The ring thread was clipped at two points across the maximal diameter of the mucosal defect; D: A third clip was placed across to the edge of the mucosal defect, and after pulling the first and second clips, the mucosal defect area slid together; E: The mucosal defect was smaller, and closing it with additional clips was easier. ESD: Endoscopic submucosal dissection.