Digestive Endoscopy 2014; 26 (Suppl. 2): 41–45
doi: 10.1111/den.12253
Endoscopic diagnosis and treatment of non-ampullary superficial duodenal tumors
Endoscopic tissue shielding with polyglycolic acid sheets, fibrin glue and clips to prevent delayed perforation after duodenal endoscopic resection Hisashi Doyama, Kei Tominaga, Naohiro Yoshida, Kenichi Takemura and Shinya Yamada Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
The incidence of delayed perforation after endoscopic resection for superficial non-ampullary duodenal epithelial tumors is extremely high. Endoscopic tissue shielding with polyglycolic acid (PGA) sheets and fibrin glue is a promising method to prevent delayed perforation after endoscopic resection in the duodenum. However, we often encounter difficulty when covering an artificial ulcer with PGA sheets after endoscopic
INTRODUCTION
P
RIMARY DUODENAL CARCINOMA comprises approximately 0.5% of malignant gastrointestinal tumors.1 The incidence of duodenal adenomas detected in screening endoscopy is reportedly 0.04–0.27%.2,3 Although the incidence of superficial non-ampullary duodenal epithelial tumors (SNADET) is low, recent developments in endoscopic technology, such as high-resolution endoscopy and image-enhanced endoscopy, may increase the chances of detecting SNADET.4 Endoscopic resection, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are treatments for SNADET.4–7 However, the incidence of delayed perforation after endoscopic resection for SNADET is significantly higher than in any other part of the digestive tract. Ono et al. reported that the occurrence of delayed perforation is approximately 6% in ESD and 1.2% in EMR for SNADET.8 Inoue et al. reported that delayed perforation after duodenal endoscopic resection occurred in 6.3% of patients with SNADET.4 The incidences of delayed per-
resection. We report three cases of postoperative ulcers covered by PGA sheets, fibrin glue, and clips. Key words: delayed perforation, endoscopic resection, polyglycolic acid sheet, superficial non-ampullary duodenal epithelial tumor
foration after gastric, colonic, and esophageal ESD were reportedly 0.45%,9 0.4–0.9%,10–13 and extremely rare,14–16 respectively. Recently Takimoto et al. reported endoscopic tissue shielding with polyglycolic acid (PGA) sheets (Neoveil; Gunze Co., Kyoto, Japan) and fibrin glue (Beriplast P combiset; CSL Behring Pharma, Tokyo, Japan) to prevent delayed perforation after duodenal endoscopic resection.17 This method is considered to be useful, simple, and safe. However, we often encounter difficulty when covering an artificial ulcer with pieces of a PGA sheet after endoscopic resection because of gravitational influence in the duodenal lumen, and early slipping of the sheets. To improve the coverage, we attempted to maintain the PGA sheets with fibrin glue and clips. The present case series study was approved by the institutional review board of Ishikawa Prefectural Central Hospital, and all patients provided written informed consent.
CASE REPORTS Case 1
A
bs_bs_banner
Corresponding: Hisashi Doyama, Department of Gastroenterology, Ishikawa Prefectural Central Hospital, 2-1 Kuratsuki-Higashi, Kanazawa city, Ishikawa 920-8530, Japan. Email: doyama.134 @ipch.jp Received 28 November 2013; accepted 17 January 2014.
79-YEAR-OLD WOMAN with a 15-mm, protruding mucosal duodenal adenocarcinoma identified on the opposite side of the main papilla in the second part of the duodenum was referred to our hospital (Fig. 1a). The lesion was removed en bloc by EMR with a cap-fitted endoscope (EMR-C) (Fig. 1b). The resected specimen was 23 × 18 mm. Pieces of the PGA sheet were delivered to the post-EMR
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
41
42
H. Doyama et al.
Figure 1 Case 1. (a) Protruding lesion located across the duodenal lumen from main papilla, 15 mm in size. (b) Endoscopic image of ulcer after endoscopic mucosal resection (EMR). (c,d) Pieces of polyglycolic acid (PGA) sheet were delivered to the post-EMR ulcer sheet by sheet. The ulcer was covered with three PGA sheets, fixed in place with fibrin glue. (e) One side of the PGA sheets was fixed to the edge of the ulcer with a clip. (f) The PGA sheet was cut to approximately 15 × 5 mm and held with biopsy forceps to be delivered to the ulcer.
Digestive Endoscopy 2014; 26 (Suppl. 2): 41–45
a
b
c
d
e
f
ulcer sheet by sheet. The ulcer was covered with three pieces of the PGA sheet and fixed in place with fibrin glue (Fig. 1c,d). We used the method reported by Takimoto et al.17 The only tools used in this method are biopsy forceps and two spray tubes. The PGA sheet was cut to approximately 15 × 5 mm and held with biopsy forceps with the cap of the biopsy valve off to be delivered to the ulcer (Fig. 1f). The base of the ulcer can be entirely covered by applying several sheets, followed by spraying fibrinogen through a spray tube to adhere the sheets to the ulcer, and then spraying thrombin through another spray tube. However, the PGA sheets were slippery because of gravitational influence in the duodenal lumen. We fixed one side of the PGA sheets using a clip. The
clip was attached to the edge of the ulcer (Fig. 1e). Procedure time for shielding with the PGA sheets plus fibrin glue and clip was 22 min. No postoperative delayed perforation occurred
Case 2 A 49-year-old man with a 20-mm, protruding mucosal duodenal adenocarcinoma located in the posterior wall of the second part of the duodenum was referred to our hospital (Fig. 2a). The lesion was removed en bloc by EMR. The resected specimen was 25 × 20 mm. The ulcer was entirely covered with three pieces of PGA sheet. The sheets were fixed with four clips before using fibrin glue (Fig. 2b).
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2014; 26 (Suppl. 2): 41–45
a
Delayed perforation after duodenal EMR 43
b
Figure 2 Case 2. (a) Protruding lesion located in the posterior wall of the second part of the duodenum, 20 mm in size. (b) The ulcer was covered with three polyglycolic acid sheets, fixed with four clips before using fibrin glue.
a
b
c
d
Figure 3 Case 3. (a) Protruding lesion located in the lateral wall of the second part of the duodenum, 15 mm in size. (b) The ulcer was entirely covered with two polyglycolic acid (PGA) sheets and three clips (c) Fibrin glue was subsequently used. (d) The PGA sheets were still attached to the ulcer at 1 week after treatment.
The procedure time in shielding with the PGA sheets plus fibrin glue and clips was 9 min. No postoperative delayed perforation occurred.
Case 3 A 50-year-old man with a 15-mm, protruding mucosal duodenal adenocarcinoma identified on the opposite side of the main papilla in the second part of the duodenum was referred to our hospital (Fig. 3a). The lesion was removed en bloc by EMR-C. The resected specimen was 18 × 14 mm. The first PGA sheet was slippery, not well maintained on the bottom of the post-EMR ulcer, and was immediately fixed with the
first clip. The ulcer was entirely covered with two PGA sheets and three clips (Fig. 3b). Fibrin glue was subsequently sprayed (Fig. 3c). Procedure time was 14 min. No postoperative delayed perforation occurred. The PGA sheets were still attached to the ulcer 1 week after treatment (Fig. 3d).
DISCUSSION
I
N GASTRIC DELAYED perforation, patients undergoing emergency surgery show a favorable course and are discharged within a few weeks without any operationrelated complications.9 In contrast, delayed perforation after
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
44
H. Doyama et al.
endoscopic resection in the duodenum is a hazardous complication. As a result of the anatomical position, duodenal surgery as a treatment for delayed perforation is highly invasive. As reported by Inoue et al., if patients with duodenal delayed perforation recover from chosen non-surgical treatment, they may require long-term conservative treatment.4 Tumor location distal to the main papilla is significantly associated with the occurrence of delayed perforation.4,8 Direct exposure of bile and pancreatic juices to the duodenal ulcer after endoscopic resection results in delayed perforation.8,18,19 Protease inhibitors may be useful for preventing delayed perforation, but this treatment is not capable of completely inhibiting enzymatic activity.20 Therefore, completely closing a postoperative duodenal ulcer by prophylactic clipping, including combination with an endoloop,21 might possibly prevent delayed perforation. However, the size of the clip is insufficient to successfully close a large postoperative ulcer, and the grasping power of the conventional clip is insufficient to hold a large ulcer.20 In fact, Inoue et al. reported that delayed perforation occurred in some patients despite carrying out prophylactic clipping. In those cases, some of the clips had fallen off.4 It is problematic that prophylactic clips fall off and leave the exposed tissue vulnerable to digestive fluids.8 Endoscopic tissue shielding with PGA sheets and the fibrin glue is considered a promising method to prevent delayed perforation after endoscopic resection in the duodenum. Takimoto et al. mentioned that this method has the following three advantages. First, it is simple compared with clip closure of large mucosal defects. Second, the PGA sheets and the fibrin glue are spontaneously absorbed within 4–15 weeks. Third, as the PGA sheets and the fibrin glue have been applied in many fields of surgery,22,23 the safety level may be high.17 However, covering with pieces of a PGA sheet for a postoperative ulcer is often difficult because of gravitational influence in the duodenal lumen. Moreover, we often encountered early slippage of the sheets from the postoperative ulcer. We reported three successful cases where the PGA sheets were fixed not only with fibrin glue, but also with additional clips. The additional clips may improve the covering ability of the PGA sheets for the postoperative ulcer. A new clip device, the over-the-scope clip (OTSC) (Ovesco Endoscopy, Tübingen, Germany), was recently developed.24 This new clip provides more strength and better tissue capture compared with conventional clips. Mori et al.20 and Nishiyama et al.25 reported complete closure of post-ESD duodenal ulcers using the OTSC. Although the OTSC is a promising method to prevent delayed perforation after endoscopic resection in the duodenum, it might be difficult to completely close defects >30 mm in diameter,25
Digestive Endoscopy 2014; 26 (Suppl. 2): 41–45
and it is more expensive than endoscopic tissue shielding with PGA sheets. The effectiveness of the OTSC should be evaluated in the future. The present case series has several limitations. We dealt with only small SNADET resected en bloc. Piecemeal EMR and ESD were significant risk factors for delayed perforation, but the incidence of delayed perforation after en-bloc EMR was low.4 In the future, PGA sheets fixed with fibrin glue and clips should be evaluated in a large ulcer, for example, an ulcer after piecemeal EMR or ESD. Moreover, it is thought to be inefficient when many small PGA sheets are delivered to a large postoperative ulcer sheet by sheet. An efficient delivery system should be developed. In conclusion, the present case series illustrates that endoscopic tissue shielding with PGA sheets, fibrin glue and clips may efficiently prevent delayed perforation after duodenal endoscopic resection.
CONFLICT OF INTERESTS
A
UTHORS DECLARE NO conflict of interests for this article.
REFERENCES 1 Alwmark A, Andersson A, Lasson A. Primary carcinoma of the duodenum. Ann. Surg. 1980; 191: 13–8. 2 Yokoyama T, Saito D, Kondo H et al. The endoscopic diagnosis of duodenal malignant neoplasms. Stomach Intestine 1993; 28: 641–9. (Japanese with English summary.) 3 Mitsuzaki K, Fukunaga K, Uneda N et al. Clinicopathological study of duodenal adenoma detected on gastroscopic screening. Nichishougankenshinshi 2008; 46: 378–86. (Japanese with English summary.) 4 Inoue T, Uedo N, Yamashita T et al. Delayed perforation: A hazardous complication of endoscopic resection for non-ampullary duodenal neoplasm. Dig. Endosc. 2013. doi: 10.1111/den.12104 [Epub 29 Apr 2013]. 5 Hirasawa R, Iishi H, Tatsuta M, Ishiguro S. Clinicopathologic features and endoscopic resection of duodenal adenocarcinomas and adenomas with the submucosal saline injection technique. Gastrointest. Endosc. 1997; 46: 507–13. 6 Ahmad NA, Kochman ML, Long WB, Furth EE, Ginsberg GG. Efficacy, safety, and clinical outcomes of endoscopic mucosal resection: A study of 101 cases. Gastrointest. Endosc. 2002; 55: 390–6. 7 Fanning SB, Bourke MJ, Williams SJ, Chung A, Kariyawasam VC. Giant laterally spreading tumors of the duodenum: Endoscopic resection outcomes, limitations, and caveats. Gastrointest. Endosc. 2012; 75: 805–12. 8 Ono H, Nonaka S, Uedo N et al. Clinical issues of duodenal EMR/ESD. Stomach Intestine 2011; 46: 1669–77. (Japanese with English summary.)
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2014; 26 (Suppl. 2): 41–45
9 Hanaoka N, Uedo N, Ishihara R et al. Clinical features and outcomes of delayed perforation after endoscopic submucosal dissection for early gastric cancer. Endoscopy 2010; 42: 1112–5. 10 Saito Y, Uraoka T, Yamaguchi Y et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissection. Gastrointest. Endosc. 2010; 72: 1217–25. 11 Tanaka S, Tamegai Y, Tsuda S, Saito Y, Yahagi N, Yamano HO. Multicenter questionnaire survey on the current situation of colorectal endoscopic submucosal dissection in Japan. Dig. Endosc. 2010; 22: S2–8. 12 Shono T, Ishikawa K, Ochiai Y et al. Feasibility of endoscopic submucosal dissection: A new technique for en bloc resection of a large superficial tumor in the colon and rectum. Int. J. Surg. Oncol. 2011; doi: 10.1155/2011/948293 [Epub 2 May 2011]. 13 Niimi K, Fujishiro M, Goto O, Kodashima S, Koike K. Safety and efficacy of colorectal endoscopic submucosal dissection by trainee endoscopists. Dig. Endosc. 2012; 24: 154–8. 14 Ishihara R, Tanaka H, Iishi H et al. Long-term outcome of esophageal mucosal squamous cell carcinoma without lymphovascular involvement after endoscopic resection. Cancer 2008; 112: 2166–72. 15 Ishihara R, Iishi H, Uedo N et al. Comparison of EMR and endoscopic submucosal dissection for en bloc resection of early esophageal cancers in Japan. Gastrointest. Endosc. 2008; 68: 1066–72. 16 Shimizu Y, Tsukagoshi H, Fujita M, Hosokawa M, Kato M, Asaka M. Long-term outcome after endoscopic mucosal resection in patients with esophageal squamous cell carcinoma invading the muscularis mucosae or deeper. Gastrointest. Endosc. 2002; 56: 387–90.
Delayed perforation after duodenal EMR 45
17 Takimoto K, Toyonaga T, Matsuyama K. Endoscopic tissue shielding to prevent delayed perforation associated with endoscopic submucosal dissection for duodenal neoplasms. Endoscopy 2012; 44: E414–5. 18 Honda T, Yamamoto H, Osawa H et al. Endoscopic submucosal dissection for superficial duodenal neoplasms. Dig. Endosc. 2009; 21: 270–4. 19 Shinoda M, Makino A, Wada M et al. Successful endoscopic submucosal dissection for mucosal cancer of the duodenum. Dig. Endosc. 2010; 22: 49–52. 20 Mori H, Fujihara S, Kobara H et al. Successful closing of duodenal ulcer after endoscopic submucosal dissection with overthe-scope clip to prevent delayed perforation. Dig. Endosc. 2013; 25: 459–61. 21 Matsuda T, Fujii T, Emura F et al. Complete closure of a large defect after EMR of a lateral spreading colorectal tumor when using a two-channel colonoscope. Gastrointest. Endosc. 2004; 60: 836–8. 22 Ueda K, Tanaka T, Hayashi M et al. Mesh-based pneumostasis contributes to preserving gas exchange capacity and promoting rehabilitation after lung resection. J. Surg. Res. 2011; 167: e71–5. 23 Uemura K, Murakami Y, Hayashidani Y et al. Combination of polyglicolic acid felt and fibrin glue for prevention of pancreatic fistula following pancreaticoduodenectomy. Hepatogastroenterology 2009; 56: 1538–41. 24 Gubler C, Bauerfeind P. Endoscopic closure of iatrogenic gastrointestinal tract perforations with the over-the-scope clip. Digestion 2012; 85: 302–7. 25 Nishiyama N, Mori H, Kobara H et al. Efficacy and safety of over-the-scope clip: Including complications after endoscopic submucosal dissection. World J. Gastroenterol. 2013; 19: 2752– 60.
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
doi: 10.1111/den.12253
Endoscopic diagnosis and treatment of non-ampullary superficial duodenal tumors
Endoscopic tissue shielding with polyglycolic acid sheets, fibrin glue and clips to prevent delayed perforation after duodenal endoscopic resection Hisashi Doyama, Kei Tominaga, Naohiro Yoshida, Kenichi Takemura and Shinya Yamada Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
The incidence of delayed perforation after endoscopic resection for superficial non-ampullary duodenal epithelial tumors is extremely high. Endoscopic tissue shielding with polyglycolic acid (PGA) sheets and fibrin glue is a promising method to prevent delayed perforation after endoscopic resection in the duodenum. However, we often encounter difficulty when covering an artificial ulcer with PGA sheets after endoscopic
INTRODUCTION
P
RIMARY DUODENAL CARCINOMA comprises approximately 0.5% of malignant gastrointestinal tumors.1 The incidence of duodenal adenomas detected in screening endoscopy is reportedly 0.04–0.27%.2,3 Although the incidence of superficial non-ampullary duodenal epithelial tumors (SNADET) is low, recent developments in endoscopic technology, such as high-resolution endoscopy and image-enhanced endoscopy, may increase the chances of detecting SNADET.4 Endoscopic resection, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are treatments for SNADET.4–7 However, the incidence of delayed perforation after endoscopic resection for SNADET is significantly higher than in any other part of the digestive tract. Ono et al. reported that the occurrence of delayed perforation is approximately 6% in ESD and 1.2% in EMR for SNADET.8 Inoue et al. reported that delayed perforation after duodenal endoscopic resection occurred in 6.3% of patients with SNADET.4 The incidences of delayed per-
resection. We report three cases of postoperative ulcers covered by PGA sheets, fibrin glue, and clips. Key words: delayed perforation, endoscopic resection, polyglycolic acid sheet, superficial non-ampullary duodenal epithelial tumor
foration after gastric, colonic, and esophageal ESD were reportedly 0.45%,9 0.4–0.9%,10–13 and extremely rare,14–16 respectively. Recently Takimoto et al. reported endoscopic tissue shielding with polyglycolic acid (PGA) sheets (Neoveil; Gunze Co., Kyoto, Japan) and fibrin glue (Beriplast P combiset; CSL Behring Pharma, Tokyo, Japan) to prevent delayed perforation after duodenal endoscopic resection.17 This method is considered to be useful, simple, and safe. However, we often encounter difficulty when covering an artificial ulcer with pieces of a PGA sheet after endoscopic resection because of gravitational influence in the duodenal lumen, and early slipping of the sheets. To improve the coverage, we attempted to maintain the PGA sheets with fibrin glue and clips. The present case series study was approved by the institutional review board of Ishikawa Prefectural Central Hospital, and all patients provided written informed consent.
CASE REPORTS Case 1
A
bs_bs_banner
Corresponding: Hisashi Doyama, Department of Gastroenterology, Ishikawa Prefectural Central Hospital, 2-1 Kuratsuki-Higashi, Kanazawa city, Ishikawa 920-8530, Japan. Email: doyama.134 @ipch.jp Received 28 November 2013; accepted 17 January 2014.
79-YEAR-OLD WOMAN with a 15-mm, protruding mucosal duodenal adenocarcinoma identified on the opposite side of the main papilla in the second part of the duodenum was referred to our hospital (Fig. 1a). The lesion was removed en bloc by EMR with a cap-fitted endoscope (EMR-C) (Fig. 1b). The resected specimen was 23 × 18 mm. Pieces of the PGA sheet were delivered to the post-EMR
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
41
42
H. Doyama et al.
Figure 1 Case 1. (a) Protruding lesion located across the duodenal lumen from main papilla, 15 mm in size. (b) Endoscopic image of ulcer after endoscopic mucosal resection (EMR). (c,d) Pieces of polyglycolic acid (PGA) sheet were delivered to the post-EMR ulcer sheet by sheet. The ulcer was covered with three PGA sheets, fixed in place with fibrin glue. (e) One side of the PGA sheets was fixed to the edge of the ulcer with a clip. (f) The PGA sheet was cut to approximately 15 × 5 mm and held with biopsy forceps to be delivered to the ulcer.
Digestive Endoscopy 2014; 26 (Suppl. 2): 41–45
a
b
c
d
e
f
ulcer sheet by sheet. The ulcer was covered with three pieces of the PGA sheet and fixed in place with fibrin glue (Fig. 1c,d). We used the method reported by Takimoto et al.17 The only tools used in this method are biopsy forceps and two spray tubes. The PGA sheet was cut to approximately 15 × 5 mm and held with biopsy forceps with the cap of the biopsy valve off to be delivered to the ulcer (Fig. 1f). The base of the ulcer can be entirely covered by applying several sheets, followed by spraying fibrinogen through a spray tube to adhere the sheets to the ulcer, and then spraying thrombin through another spray tube. However, the PGA sheets were slippery because of gravitational influence in the duodenal lumen. We fixed one side of the PGA sheets using a clip. The
clip was attached to the edge of the ulcer (Fig. 1e). Procedure time for shielding with the PGA sheets plus fibrin glue and clip was 22 min. No postoperative delayed perforation occurred
Case 2 A 49-year-old man with a 20-mm, protruding mucosal duodenal adenocarcinoma located in the posterior wall of the second part of the duodenum was referred to our hospital (Fig. 2a). The lesion was removed en bloc by EMR. The resected specimen was 25 × 20 mm. The ulcer was entirely covered with three pieces of PGA sheet. The sheets were fixed with four clips before using fibrin glue (Fig. 2b).
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2014; 26 (Suppl. 2): 41–45
a
Delayed perforation after duodenal EMR 43
b
Figure 2 Case 2. (a) Protruding lesion located in the posterior wall of the second part of the duodenum, 20 mm in size. (b) The ulcer was covered with three polyglycolic acid sheets, fixed with four clips before using fibrin glue.
a
b
c
d
Figure 3 Case 3. (a) Protruding lesion located in the lateral wall of the second part of the duodenum, 15 mm in size. (b) The ulcer was entirely covered with two polyglycolic acid (PGA) sheets and three clips (c) Fibrin glue was subsequently used. (d) The PGA sheets were still attached to the ulcer at 1 week after treatment.
The procedure time in shielding with the PGA sheets plus fibrin glue and clips was 9 min. No postoperative delayed perforation occurred.
Case 3 A 50-year-old man with a 15-mm, protruding mucosal duodenal adenocarcinoma identified on the opposite side of the main papilla in the second part of the duodenum was referred to our hospital (Fig. 3a). The lesion was removed en bloc by EMR-C. The resected specimen was 18 × 14 mm. The first PGA sheet was slippery, not well maintained on the bottom of the post-EMR ulcer, and was immediately fixed with the
first clip. The ulcer was entirely covered with two PGA sheets and three clips (Fig. 3b). Fibrin glue was subsequently sprayed (Fig. 3c). Procedure time was 14 min. No postoperative delayed perforation occurred. The PGA sheets were still attached to the ulcer 1 week after treatment (Fig. 3d).
DISCUSSION
I
N GASTRIC DELAYED perforation, patients undergoing emergency surgery show a favorable course and are discharged within a few weeks without any operationrelated complications.9 In contrast, delayed perforation after
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
44
H. Doyama et al.
endoscopic resection in the duodenum is a hazardous complication. As a result of the anatomical position, duodenal surgery as a treatment for delayed perforation is highly invasive. As reported by Inoue et al., if patients with duodenal delayed perforation recover from chosen non-surgical treatment, they may require long-term conservative treatment.4 Tumor location distal to the main papilla is significantly associated with the occurrence of delayed perforation.4,8 Direct exposure of bile and pancreatic juices to the duodenal ulcer after endoscopic resection results in delayed perforation.8,18,19 Protease inhibitors may be useful for preventing delayed perforation, but this treatment is not capable of completely inhibiting enzymatic activity.20 Therefore, completely closing a postoperative duodenal ulcer by prophylactic clipping, including combination with an endoloop,21 might possibly prevent delayed perforation. However, the size of the clip is insufficient to successfully close a large postoperative ulcer, and the grasping power of the conventional clip is insufficient to hold a large ulcer.20 In fact, Inoue et al. reported that delayed perforation occurred in some patients despite carrying out prophylactic clipping. In those cases, some of the clips had fallen off.4 It is problematic that prophylactic clips fall off and leave the exposed tissue vulnerable to digestive fluids.8 Endoscopic tissue shielding with PGA sheets and the fibrin glue is considered a promising method to prevent delayed perforation after endoscopic resection in the duodenum. Takimoto et al. mentioned that this method has the following three advantages. First, it is simple compared with clip closure of large mucosal defects. Second, the PGA sheets and the fibrin glue are spontaneously absorbed within 4–15 weeks. Third, as the PGA sheets and the fibrin glue have been applied in many fields of surgery,22,23 the safety level may be high.17 However, covering with pieces of a PGA sheet for a postoperative ulcer is often difficult because of gravitational influence in the duodenal lumen. Moreover, we often encountered early slippage of the sheets from the postoperative ulcer. We reported three successful cases where the PGA sheets were fixed not only with fibrin glue, but also with additional clips. The additional clips may improve the covering ability of the PGA sheets for the postoperative ulcer. A new clip device, the over-the-scope clip (OTSC) (Ovesco Endoscopy, Tübingen, Germany), was recently developed.24 This new clip provides more strength and better tissue capture compared with conventional clips. Mori et al.20 and Nishiyama et al.25 reported complete closure of post-ESD duodenal ulcers using the OTSC. Although the OTSC is a promising method to prevent delayed perforation after endoscopic resection in the duodenum, it might be difficult to completely close defects >30 mm in diameter,25
Digestive Endoscopy 2014; 26 (Suppl. 2): 41–45
and it is more expensive than endoscopic tissue shielding with PGA sheets. The effectiveness of the OTSC should be evaluated in the future. The present case series has several limitations. We dealt with only small SNADET resected en bloc. Piecemeal EMR and ESD were significant risk factors for delayed perforation, but the incidence of delayed perforation after en-bloc EMR was low.4 In the future, PGA sheets fixed with fibrin glue and clips should be evaluated in a large ulcer, for example, an ulcer after piecemeal EMR or ESD. Moreover, it is thought to be inefficient when many small PGA sheets are delivered to a large postoperative ulcer sheet by sheet. An efficient delivery system should be developed. In conclusion, the present case series illustrates that endoscopic tissue shielding with PGA sheets, fibrin glue and clips may efficiently prevent delayed perforation after duodenal endoscopic resection.
CONFLICT OF INTERESTS
A
UTHORS DECLARE NO conflict of interests for this article.
REFERENCES 1 Alwmark A, Andersson A, Lasson A. Primary carcinoma of the duodenum. Ann. Surg. 1980; 191: 13–8. 2 Yokoyama T, Saito D, Kondo H et al. The endoscopic diagnosis of duodenal malignant neoplasms. Stomach Intestine 1993; 28: 641–9. (Japanese with English summary.) 3 Mitsuzaki K, Fukunaga K, Uneda N et al. Clinicopathological study of duodenal adenoma detected on gastroscopic screening. Nichishougankenshinshi 2008; 46: 378–86. (Japanese with English summary.) 4 Inoue T, Uedo N, Yamashita T et al. Delayed perforation: A hazardous complication of endoscopic resection for non-ampullary duodenal neoplasm. Dig. Endosc. 2013. doi: 10.1111/den.12104 [Epub 29 Apr 2013]. 5 Hirasawa R, Iishi H, Tatsuta M, Ishiguro S. Clinicopathologic features and endoscopic resection of duodenal adenocarcinomas and adenomas with the submucosal saline injection technique. Gastrointest. Endosc. 1997; 46: 507–13. 6 Ahmad NA, Kochman ML, Long WB, Furth EE, Ginsberg GG. Efficacy, safety, and clinical outcomes of endoscopic mucosal resection: A study of 101 cases. Gastrointest. Endosc. 2002; 55: 390–6. 7 Fanning SB, Bourke MJ, Williams SJ, Chung A, Kariyawasam VC. Giant laterally spreading tumors of the duodenum: Endoscopic resection outcomes, limitations, and caveats. Gastrointest. Endosc. 2012; 75: 805–12. 8 Ono H, Nonaka S, Uedo N et al. Clinical issues of duodenal EMR/ESD. Stomach Intestine 2011; 46: 1669–77. (Japanese with English summary.)
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2014; 26 (Suppl. 2): 41–45
9 Hanaoka N, Uedo N, Ishihara R et al. Clinical features and outcomes of delayed perforation after endoscopic submucosal dissection for early gastric cancer. Endoscopy 2010; 42: 1112–5. 10 Saito Y, Uraoka T, Yamaguchi Y et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissection. Gastrointest. Endosc. 2010; 72: 1217–25. 11 Tanaka S, Tamegai Y, Tsuda S, Saito Y, Yahagi N, Yamano HO. Multicenter questionnaire survey on the current situation of colorectal endoscopic submucosal dissection in Japan. Dig. Endosc. 2010; 22: S2–8. 12 Shono T, Ishikawa K, Ochiai Y et al. Feasibility of endoscopic submucosal dissection: A new technique for en bloc resection of a large superficial tumor in the colon and rectum. Int. J. Surg. Oncol. 2011; doi: 10.1155/2011/948293 [Epub 2 May 2011]. 13 Niimi K, Fujishiro M, Goto O, Kodashima S, Koike K. Safety and efficacy of colorectal endoscopic submucosal dissection by trainee endoscopists. Dig. Endosc. 2012; 24: 154–8. 14 Ishihara R, Tanaka H, Iishi H et al. Long-term outcome of esophageal mucosal squamous cell carcinoma without lymphovascular involvement after endoscopic resection. Cancer 2008; 112: 2166–72. 15 Ishihara R, Iishi H, Uedo N et al. Comparison of EMR and endoscopic submucosal dissection for en bloc resection of early esophageal cancers in Japan. Gastrointest. Endosc. 2008; 68: 1066–72. 16 Shimizu Y, Tsukagoshi H, Fujita M, Hosokawa M, Kato M, Asaka M. Long-term outcome after endoscopic mucosal resection in patients with esophageal squamous cell carcinoma invading the muscularis mucosae or deeper. Gastrointest. Endosc. 2002; 56: 387–90.
Delayed perforation after duodenal EMR 45
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