Underwater endoscopic mucosal resection for a tumor located in the free jejunal graft

Junki Toyosawaa, Yasushi Yamasakia,b, Tsuyoshi Fujimotoa, Shouichi Tanakaa

Iwakuni Clinical Center, National Hospital Organization, Yamaguchi; Okayama University Hospital, Okayama, Japan

aDepartment of Gastroenterology, Iwakuni Clinical Center, National Hospital Organization, Yamaguchi (Junki Toyosawa, Yasushi Yamasaki, Tsuyoshi Fujimoto, Shouichi Tanaka), bDepartment of Gastroenterology, Okayama University Hospital, Okayama (Yasushi Yamasaki), Japan

Correspondence to: Yasushi Yamasaki, MD, PhD, Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama-city, Okayama 700-8558, Japan, e-mail: yasshifive@yahoo.co.jp
Received 29 March 2019; accepted 8 April 2019; published online 8 May 2019
DOI: https://doi.org/10.20524/aog.2019.0383
© 2019 Hellenic Society of Gastroenterology

Annals of Gastroenterology (2019) 32, 424

Endoscopic resection for a tumor located in the free jejunum after surgery is challenging because of the narrow and tortuous lumen. Theoretically, underwater conditions improve the maneuverability of the endoscope and the visibility of the resection site [1,2]. Thus, we applied underwater endoscopic mucosal resection (UEMR) for a tumor located in the free jejunum.

A woman in her 70s underwent esophagectomy for esophageal cancer and subsequent surveillance esophagogastroduodenoscopy, during which a 15-mm pedunculated tumor was detected in the free jejunum. However, approaching the tumor while maintaining good visualization was difficult, because there was a moderate stricture at the pharynx–jejunum anastomosis and the tumor was located in the upper part of the free jejunum. Thus, we performed UEMR. Before the procedure, the patient was kept in a slight head-up position to avoid aspiration. After air deflation in the free jejunum, the lumen was filled with physiological saline. In this underwater condition, we could easily approach the tumor and maintain a clear visual field. The tumor floated as after submucosal injection; thus, it was easily captured by a snare (Captivator II; Boston Scientific, Marlborough, MA, USA) and removed en bloc with electrical current. After resection, clip closure was performed in the underwater condition [3]. Histological examination revealed intramucosal cancer without lymphovascular invasion. No adverse events occurred, and no recurrence was shown at the 3-month follow up (Fig. 1A-D, Fig. 2A-B).

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Figure 1 Underwater endoscopic mucosal resection for a tumor in the free jejunum. (A) A 15-mm lesion was detected in the free jejunum. (B) The lesion floated up in the underwater conditions. (C) The lesion was easily captured by a polypectomy snare. (D) The lesion was completely removed by underwater endoscopic resection without bleeding

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Figure 2 Histopathological examination and follow-up endoscopy. (A) Histopathological examination of the tumor revealed intramucosal cancer with an adenoma component (hematoxylin and eosin stain, ×10). (B) There was no recurrence 3 months after resection

UEMR improved the maneuverability of the endoscope and was safely applicable to the lesion in the free jejunum described here.

Acknowledgment

We thank Angela Morben, DVM, ELS, from Edanz Group (www.edanzediting.com/ac), for editing a draft of this manuscript.

References

1. Yamasaki Y, Uedo N, Takeuchi Y, et al. Underwater endoscopic mucosal resection for superficial nonampullary duodenal adenomas. Endoscopy 2018;50:154-158.

2. Hirai M, Yamasaki Y, Harada K, Okada H. Underwater endoscopic mucosal resection for anal canal neoplasia in a patient with human immunodeficiency virus infection. Ann Gastroenterol 2018;31:522.

3. Yamasaki Y, Kanzaki H, Kawahara Y, Okada H. Underwater endoclip closure after endoscopic resection for duodenal denomas. Ann Gastroenterol 2018;31:121.

Notes

Conflict of Interest: None