Endoscopic submucosal dissection (ESD) in the duodenum is technically demanding because of its complex anatomy and the high risk of perforation 1 2. ESD involving the major duodenal papilla (ESDIP) is particularly challenging and is performed only in selected high-volume centers 3. Resection of the papilla exposes the mucosal defect to bile and pancreatic juice, increasing the risk of bleeding and perforation. Therefore, a device that enables safe and swift resection is needed. The recently developed new-generation HybridKnife flex (Erbe, Tübingen, Germany) combines both submucosal injection and dissection within a single device, eliminating the need for device exchange (Fig. 1). We report the first case of ESDIP performed using the HybridKnife flex 4. A 77-year-old woman was found to have a laterally spreading 30-mm tumor on the inner wall of the descending duodenum involving the major papilla (Fig. 2, Video 1). Biopsy confirmed an adenoma. ESDIP was performed using the HybridKnife flex T-Type (1. 5 mm), which provides excellent tissue purchase and strong hemostatic capability when used with the needleless high-pressure water-jet system (ERBEJET 2). A therapeutic endoscope (EG-840T; Fujifilm, Tokyo, Japan) with an EP-8000 light source (Fujifilm, Tokyo, Japan) was used. Electrosurgical settings included EndoCut U mode (Effect 1, Duration 4, Interval 2) and PreciseSect mode (Effect 3. 5) with a VIO 3 electrosurgical generator (Erbe, Tübingen, Germany). High-pressure submucosal injection of saline mixed with indigo carmine through the device tip provided sufficient submucosal elevation for safe incision and dissection. The needleless system allowed instant, controlled injection and enabled efficient dissection without injection-related bleeding. The papillary portion and the remaining lesion were removed safely, with a total procedure time of 59 minutes. Pancreaticobiliary drainage was performed immediately after resection, and histopathology confirmed curative R0 resection. The HybridKnife flex may facilitate safe and efficient ESD for technically challenging duodenal papillary lesions. EndoscopyUCTNCodeTTT₁AO₂AG₃AD Article published online: 05 February 2026 © 2026. The Author (s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https: //creativecommons. org/licenses/by/4. 0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany
Ikenoyama et al. (Thu,) studied this question.