A 55-year-old man, during a routine screening gastroscopic examination, was found to be harboring an incipient neoplasm on the horizontal part of the duodenum. The lesion measured approximately 40×35 mm. Its surface morphology exhibited irregularity and a villous-like appearance under linked color imaging or blue light imaging, with uneven distribution and marginalization of white opaque substance. Abdominal enhanced computed tomography showed no lymphatic or organ metastasis ([Fig. 1]). The patient was admitted as an inpatient and underwent endoscopic submucosal dissection (ESD) under general anesthesia ([Video 1]). Significant challenges were encountered during this procedure, specifically during the circumferential mucosal incision, and particularly on the anal side of the lesion. To overcome the difficulty, we employed a colonoscope (EC-L600ZP7; Fujifilm, Tokyo, Japan) and applied abdominal pressure, which enhanced endoscope stability and allowed the circumferential incision to be successfully completed. We then used clips and dental floss for traction on the oral side of the lesion. This improved visualization of the submucosal layer and facilitated continuous pulling towards the oral side, aiding the approach of the endoscope's tip. We transitioned to a gastroscope (EG-601WR; Fujifilm, Tokyo, Japan) to complete dissection in the submucosal layer. The procedure was completed in 285 minutes ([Fig. 2]). After surgery, no complications such as perforation, hemorrhage, or pyrexia occurred. Histopathological analysis showed complete excision of the villous tubular adenoma, with R0 resection achieved ([Fig. 3]).
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Xian et al. (2024) studied this question.