Over-the-scope clip placement and endosponge insertion for prevention of pancreatic enzyme-induced duodenal damage after large duodenal endoscopic resection.

A 61-year-old woman with familial adenomatous polyposis and previous proctocolectomy was admitted for resection of duodenal adenomas (Spigelman classification IV). A formation of two confluent adenomas with low grade dysplasia, measuring 3.5×2.5cm with a central depression (laterally spreading tumor mixed type; Paris IIa+c), was found at the lower duodenal knee (D2/D3) (●" Fig.1a). After an attempt of endoscopic mucosal resection, endoscopic submucosal dissection was performed using hydroxyethyl starch with indigo carmine blue and a 1.5mm FlushKnife (straight type; Fujifilm, Tokyo, Japan) (●" Fig.1b). After complete resection, the denuded area had a size of 4×3cm (●" Fig.1c). Two atraumatic, 17.5mm, over-the-scope clips ‚type a‘ (OTSC; Ovesco, Tuebingen, Germany) were placed to reduce the size of the unprotected area; standard hemoclips were also placed (●" Fig.1d). However, the flow of pancreatic and biliary secretions was seen to slow. Therefore, in order to protect the mucosa from the digestive enzymes, additional duodenal vacuum sponge implantation was performed. The vacuum sponge, 2.5cm long and 1.8cm wide (Endo-Vac; Braun, Melsungen, Germany), was introduced via an overtube (US Endoscopy, Mentor, Ohio, USA), and then transported to the duodenum using a rat tooth forceps (●" Fig.1e). The tube was externalized via the nose, and suction of –125mmHg was started. Pantoprazole 40mg was administered three times a day to reduce gastric secretion. Follow-up endoscopy on postoperative Day 4 showed the sponge still in place. After sponge retrieval, no signs of perforation or aberrant wound healing were present (●" Fig.1f). The clinical course was uneventful, and laboratory results returned to normal values. Widespread endoscopic resection of duodenal tumors is technically feasible but is associatedwith complications, such as delayed bleeding and perforation, in up to 30% of cases [1, 2]. Vacuum sponge insertion is already used in endoscopic treatment for complicated abdominal surgery [3,4]. We promote its use as prophylactic treatment in addition to OTSC placement after resection of large duodenal adenomas, in order to prevent perforation or bleeding due to damage caused by pancreatic and biliary juices.