Endoscopic Mucosal Resection of Mucosal Neoplasm Located on the Duodenal Bulb through Endoscope Retroflexion

OBJECTIVE To assess the results of endoscopic mucosal resection （EMR） of benign mucosal neoplasms located on the duodenal bulb using endoscope retroflexion. METHODS This study involved 14 patients with 16 mucosal neoplasms located on the duodenal bulb. The diameter of each neoplasm was less than 15 mm. After endoscope retroflexion within the duodenum for evaluation of the size, extent and depth of the tumor, EMR was attempted with endoscope retroflexion for removing the lesion in the duodenal bulb. The rate of endoscope retroflexion, the time required for endoscope retroflexion, median operation time, curative resection rate, en bloc resection rate, complication, and median follow-up period were evaluated. RESULTS Sixteen lesions in 14 patents （median age of 56 years, 5 female, 9 male） were removed through EMR. The mean size of the lesions resected was 6.9 mm （median size of 5.5 mm, range of 3-15 mm）. Post-EMR histologic examination revealed Brunner＇s gland hyperplasia in 6, gastric mucosal metaplasia in 5, adenoma in 1, chronic inflammation in 3, and benign lymphocytic hyperplasia in 1. The curative resection rate was 100% （16/16）, and the en bloc resection rate was 94% （15/16）, with EMR. One of the lesions was piecemeal removed through EMR for its large size （15 mm） and for its involving the area from the duodenal bulb to the pyloric ring. The success rate of endoscope retroflexion within the duodenum was 94% （15/16）. The time required for endoscope retroflexion was longer for the first 10 lesions （median time of 2 min, range of 1-2.5 min） than that for the last 5 lesions （median time of 1.5 min, range of 1-2 min）. The median follow-up period was 22 months （range of 4-48 months）. During the follow-up, no residual, no pyloric or duodenal stenosis was found in any of the patients after EMR. There was no severe hemorrhage, or perforations occurring. CONCLUSION EMR of mucosal neoplasm located on the duodenal bulb through endoscope retroflexion, which is a feasible and useful adjunctive procedure, appears to be a safe and effective technique.

Study of the duodenal contractile activity during antral contractions

AIM： To investigate the hypothesis that duodenal bulb （DB） inhibition on pyloric antrum （PA） contraction is reflex. METHODS： Balloon （condom）-tipped tube was introduced into 1^st duodenum （DD） and a manometric tube into each of PA and DD. Duodenal and antral pressure response to duodenal and then PA balloon distension with saline was recorded. These tests were repeated after separate anesthetization of DD and PA. RESULTS： Two and 4 mL of 1^st DD balloon distension produced no pressure changes in DD or PA （10.7±1.2 vs 9.8±1.2, 11.2±1.2 vs 11.3±1.2 on H20 respectively, P〉0.05）. Six mL distension effected 1^st DD pressure rise （30.6±3.4 cm H20, P 〈0.01） and PA pressure decrease （6.2±1.4 cm H20, P〈0.05）; no response in 2^nd, 3^rd and 4^th DD. There was no difference between 6, 8, and 10 mL distensions. Ten mL PA distension produced no PA or 1^st DD pressure changes （P〉 0.05）. Twenty mL distension increased PA pressure （92.4 4±10.7 cm H20, P〈0.01） and decreased 1^st DD pressure （1.6±0.3 cm H20, P〈0.01）; 30, 40, and 50 mL distension produced the same effect as the 20 mL distension （P 〉 0.05）. PA or DD distension after separate anesthetization produced no significant pressure changes in PA or DD. CONCLUSION： Large volume DD distension produced DD pressure rise denoting DD contraction and PA pressure decline denoting PA relaxation. PA relaxation upon DD contraction is postulated to be mediated through a reflex which we call duodeno-antral reflex. Meanwhile, PA distension effected DD relaxation which we suggest to be reflex and termed antro-duodenal reflex. It is suggested that these 2 reflexes, could act as investigative tools in diagnosis of gastroduodenal motility disorders.

Interesting rendezvous location in a liver transplantation patient with anastomosis stricture

An endoscopic or radiologic percutaneous approach may be an initial minimally invasive method for treating biliary strictures after living donor liver transplantation; however, cannulation of biliary strictures is sometimes difficult due to the presence of a sharp or twisted angle within the stricture or a complete stricture. When an angulated or twisted biliary stricture interrupts passage of a guidewire over the stricture, it is difficult to replace the percutaneous biliary drainage catheter with inside stents by endoscopic retrograde cholangiopancreatography. The rendezvous technique can be used to overcome this difficulty. In addition to the classical rendezvous method, in cases with complete transection of the common bile duct a modified technique involving the insertion of a snare into the subhepatic space has been successfully performed. Herein, we report a modified rendezvous technique in the duodenal bulb as an extraordinary location for a patient with duct-to-duct anastomotic complete stricture after liver transplantation.