Clin Endosc.  2023 Nov;56(6):769-777. 10.5946/ce.2022.195.

Usefulness of the S-O clip for duodenal endoscopic submucosal dissection: a propensity score-matched study

• Tanaka I
• Hirasawa D
• Saito H
• Akahira J
• Matsuda T

• KMID: 2547899
• DOI: http://doi.org/10.5946/ce.2022.195

Abstract

Background/Aims
Endoscopic submucosal dissection (ESD) for superficial non-ampullary duodenal tumors (SNADETs) is associated with a high rate of en bloc resection. However, the technique for ESD remains challenging. Recent studies have demonstrated the effectiveness of S-O clips in colonic and gastric ESD. We evaluated the efficacy and safety of duodenal ESD using an S-O clip for SNADETs.
Methods
Consecutive patients who underwent ESD for SNADETs between January 2011 and December 2021 were retrospectively enrolled. Propensity score matching analysis was used to compare patients who underwent duodenal ESD with the S-O clip (S-O group) and those who underwent conventional ESD (control group). Intraoperative perforation rate was the primary outcome, while procedure time and R0 resection rate were the secondary outcomes.
Results
After propensity score matching, 16 pairs were created: 43 and 17 in the S-O and control groups, respectively. The intraoperative perforation rate in the S-O group was significantly lower than that in the control group (p=0.033). A significant difference was observed in the procedure time between the S-O and control groups (39±9 vs. 82±30 minutes, respectively; p=0.003).
Conclusions
The S-O clip reduced the intraoperative perforation rate and procedure time, which may be useful and effective in duodenal ESD.

Keyword

Duodenal epithelial tumors; Endoscopic submucosal dissection; Propensity score

Figure

• 

  Fig. 1. The S-O clip (ZEON Medical).

• 

  Fig. 2. Endoscopic submucosal dissection (ESD) with an S-O clip for traction. (A) A 30-mm protruded lesion is seen in the anterior and lateral walls of the descending part of the duodenum. (B) Mucosal incision is performed from the oral side of the lesion. (C) The S-O clip is attached to the proximal edge of the lesion after circumferential mucosal incision. (D) By anchoring the nylon loop of the S-O clip to the opposite duodenal wall, the submucosal layer can be clearly visualized. (E) The effect of the S-O clip continues throughout the dissection procedure. (F) The lesion is dissected safely without any adverse events and the wound is covered with polyglycolic acid sheets and fibrin glue.

• 

  Fig. 3. Flowchart of the study. ESD, endoscopic submucosal dissection; SNADETs, superficial non-ampullary duodenal tumors; LECS, laparoscopy endoscopy cooperative surgery.

• 

Reference

1. Goda K, Kikuchi D, Yamamoto Y, et al. Endoscopic diagnosis of superficial non-ampullary duodenal epithelial tumors in Japan: multicenter case series. Dig Endosc. 2014; 26 Suppl 2:23–29.

2. Tsuji S, Doyama H, Tsuji K, et al. Preoperative endoscopic diagnosis of superficial non-ampullary duodenal epithelial tumors, including magnifying endoscopy. World J Gastroenterol. 2015; 21:11832–11841.

3. Kakushima N, Ono H, Takao T, et al. Method and timing of resection of superficial non-ampullary duodenal epithelial tumors. Dig Endosc. 2014; 26 Suppl 2:35–40.

4. Kato M, Sasaki M, Mizutani M, et al. Predictors of technical difficulty with duodenal ESD. Endosc Int Open. 2019; 7:E1755–E1760.

5. Jung JH, Choi KD, Ahn JY, et al. Endoscopic submucosal dissection for sessile, nonampullary duodenal adenomas. Endoscopy. 2013; 45:133–135.

6. Matsumoto S, Miyatani H, Yoshida Y. Endoscopic submucosal dissection for duodenal tumors: a single-center experience. Endoscopy. 2013; 45:136–137.

7. Hoteya S, Yahagi N, Iizuka T, et al. Endoscopic submucosal dissection for nonampullary large superficial adenocarcinoma/adenoma of the duodenum: feasibility and long-term outcomes. Endosc Int Open. 2013; 1:2–7.

8. Ritsuno H, Sakamoto N, Osada T, et al. Prospective clinical trial of traction device-assisted endoscopic submucosal dissection of large superficial colorectal tumors using the S-O clip. Surg Endosc. 2014; 28:3143–3149.

9. Hashimoto R, Hirasawa D, Iwaki T, et al. Usefulness of the S-O clip for gastric endoscopic submucosal dissection (with video). Surg Endosc. 2018; 32:908–914.

10. Hashimoto R, Hirasawa D. Duodenal endoscopic submucosal dissection with traction method using the S-O clip. Dig Endosc. 2017; 29:635.

11. Lee BI, Kim BW, Kim HK, et al. Routine mucosal closure with a detachable snare and clips after endoscopic submucosal dissection for gastric epithelial neoplasms: a randomized controlled trial. Gut Liver. 2011; 5:454–459.

12. Takimoto K, Imai Y, Matsuyama K. Endoscopic tissue shielding method with polyglycolic acid sheets and fibrin glue to prevent delayed perforation after duodenal endoscopic submucosal dissection. Dig Endosc. 2014; 26 Suppl 2:46–49.

13. Hoteya S, Kaise M, Iizuka T, et al. Delayed bleeding after endoscopic submucosal dissection for non-ampullary superficial duodenal neoplasias might be prevented by prophylactic endoscopic closure: analysis of risk factors. Dig Endosc. 2015; 27:323–330.

14. Kinoshita S, Nishizawa T, Ochiai Y, et al. Accuracy of biopsy for the preoperative diagnosis of superficial nonampullary duodenal adenocarcinoma. Gastrointest Endosc. 2017; 86:329–332.

15. Inoue T, Uedo N, Yamashina T, et al. Delayed perforation: a hazardous complication of endoscopic resection for non-ampullary duodenal neoplasm. Dig Endosc. 2014; 26:220–227.

16. Basford PJ, George R, Nixon E, et al. Endoscopic resection of sporadic duodenal adenomas: comparison of endoscopic mucosal resection (EMR) with hybrid endoscopic submucosal dissection (ESD) techniques and the risks of late delayed bleeding. Surg Endosc. 2014; 28:1594–1600.

17. Seo JY, Hong SJ, Han JP, et al. Usefulness and safety of endoscopic treatment for nonampullary duodenal adenoma and adenocarcinoma. J Gastroenterol Hepatol. 2014; 29:1692–1698.

18. Ono H, Nonaka S, Uedo N, et al. Clinical issues of duodenal EMR/ESD. Stomach Intest. 2011; 46:1669–1677.

19. Tashima T, Jinushi R, Ishii N, et al. Effectiveness of clip-and-thread traction-assisted duodenal endoscopic submucosal dissection: a propensity score-matched study (with video). Gastrointest Endosc. 2022; 95:918–928.

20. Nabi Z, Ramchandani M, Asif S, et al. Outcomes of endoscopic submucosal dissection in duodenal neuroendocrine tumors. J Gastrointest Surg. 2022; 26:275–277.

21. Dohi O, Yoshida N, Naito Y, et al. Efficacy and safety of endoscopic submucosal dissection using a scissors-type knife with prophylactic over-the-scope clip closure for superficial non-ampullary duodenal epithelial tumors. Dig Endosc. 2020; 32:904–913.