Written Transcript of Video Audio

Written Transcript of Video Audio

00:38

We present a case of a 70-year-old female with near circumferential duodenal laterally spreading lesion involving the major papilla. The patient was referred for endoscopic mucosal resection of this lesion. She has severe medical comorbidities precluding surgery, including severe COPD, rheumatoid arthritis and factor V leiden mutation on warfarin.The procedure was performed using a duodenoscope with the patient under general anaesthesia.The laterally spreading lesion was completely resected by sequential chromogelofusine EMR technique followed by en bloc endoscopic papillectomy as demonstrated in the following video.

01:21

We begin the procedure by performing an endoscopic assessment of the lesion, we can see here that the duodenal laterally spreading lesion is near circumferential with involvement of the major papilla.The laterally spreading component of this lesion extend for approximately 6 cm in the longitudinal direction.

01:43

A Carr-Locke needle is preferably used with the duodenoscope. Sequential submucosal injection beneath the LSL with a solution of succinelated gelatine, Indigo carmine, and adrenaline (diluted in 1:100,000) is performed.

02:15

We use a 15mm oval snare of a 0.47 mm thickness wire to perform a sequential mucosal resection. The LSL component is first removed. Standard EMR polypectomy settings on the ERBE electric generator of Endocut Q, Effect 3, Cut duration 1 and cut interval 6 are used.

02:57

The edge of a previous resection defect is used as an anchor for the snare to maximise control of tissue capture.

03:16

Prior to resection with electric cautery, mobility of the captured tissue relative to that of the adjacent tissue is assessed. This confirms the absence of muscularispropria involvement and therefore avoids deep mural injury.

03:52

Sequential endoscopic mucosal resection of the laterally spreading lesion proceeds as shown.

04:08

Risk of bleeding occurs by one resection, irrigation of the bleeding area with triple lumen sphincterotome revealed a transacted arterial. The size of the bleeding arterial is unsuitable for snare tip soft coagulation, and a coagulation grasper is used. Capture of the vessel results in cessation of bleeding. The forceps istented away from the mucosa and the vessel is then obliterated using soft coagulation current of 80 watts, effect 4.

05:03

Sequential endoscopic mucosal resection of the laterally spreading component is competed leaving only the ampullary adenoma.

05:23

The ampullary adenoma is captured en bloc, the snare is fully tightened and transection performed using the previously mentioned EMR settings.

05:43

A 5F single pigtail plastic pancreatic stent is prophylactically placed.Next, we also place a 10mm by 6cm fully covered metal biliary stent as a prophylaxis against microperforation and bleeding.

06:04

The patient was admitted to the ward, kept nil by mouth, and commenced on intravenous PPI and octreotide infusion. The patient developed hematemsis on day 2, but this resolved spontaneously. The postoperative course was otherwise unremarkable. She received two unit of packed cells and did not require repeat endoscopic or radiologic intervention prior to discharge.

06:30

We demonstrate through this case that endoscopic resection of large duodenal laterally spreading lesions is feasible and can be curative. Comorbid patients may preferentially benefit from endoscopic resection as this carries low morbidity and mortality compared to surgery. However, such resection should only be performedby expert endoscopists in a tertiary center where adequate support exists.