Korean J Gastroenterol.  2024 Feb;83(2):61-64. 10.4166/kjg.2023.145.

Successful Endoscopic Submucosal Dissection Using Open Peroral Endoscopic Myotomy for Duodenal Neuroendocrine Tumor

• Le NTB
• Park SJ
• Cho BJ
• Yang MA
• Song JS
• Lee WD
• Ju MJ
• Cho JW

• KMID: 2553436
• DOI: http://doi.org/10.4166/kjg.2023.145

Abstract

Duodenal neuroendocrine tumors (NETs) are subepithelial tumors that are difficult to remove endoscopically, particularly when located just beyond the pylorus. This paper reports a case of a successful endoscopic submucosal dissection (ESD) using open gastric peroral endoscopic myotomy (POEM) for a remnant duodenal NET detected after endoscopic mucosal resection (EMR). A 67-year-old male presented with a 5 mm remnant duodenal NET close to the pylorus after EMR for a duodenal polypoid lesion performed four months earlier. Duodenal ESD was performed under conscious sedation using I-type and IT II knives. The tumor adhered to the fibrotic tissue, and the submucosal cushion was insufficient. Open gastric POEM was performed concurrently during ESD, resulting in the complete resection of the NET. This case suggests that while challenging, open gastric POEM can serve as a valuable technique for endoscopic resection in cases of early gastric cancer or duodenal masses located around the pylorus.

Keyword

Neuroendocrine tumors; Endoscopic submucosal dissection; Peroral endoscopic myotomy; Duodenum

Figure

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  Fig. 1 Endoscopic submucosal dissection (ESD) using gastric open peroral endoscopic myotomy (POEM). (A) Remnant tumor in the duodenum, near the pylorus. (B) Endoscopic submucosal dissection could not proceed to duodenum. (C) Gastric open POEM was achieved. (D) ESD was completed successfully.

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  Fig. 2 Resected specimen. (A) En bloc resection was performed. (B) Hematoxylin and Eosin (H&E) staining shows a microscopic view of the neuroendocrine tumor (×100). (C) High power demonstrated nests of bland tumor cells with round to oval nuclei (H&E, ×200). (D) Synaptophysin positivity by immunohistochemistry was noted (Diaminobenzidine, ×40).

Reference

1. Panzuto F, Ramage J, Pritchard DM, et al. 2023; European Neuroendocrine Tumor Society (ENETS) 2023 guidance paper for gastroduodenal neuroendocrine tumours (NETs) G1-G3. J Neuroendocrinol. 35:e13306. DOI: 10.1111/jne.13306. PMID: 37401795.

2. Hoffmann KM, Furukawa M, Jensen RT. 2005; Duodenal neuroendocrine tumors: classification, functional syndromes, diagnosis and medical treatment. Best Pract Res Clin Gastroenterol. 19:675–697. DOI: 10.1016/j.bpg.2005.05.009. PMID: 16253893.

3. Fujihara S, Mori H, Kobara H, et al. 2016; Management of a large mucosal defect after duodenal endoscopic resection. World J Gastroenterol. 22:6595–6609. DOI: 10.3748/wjg.v22.i29.6595. PMID: 27547003. PMCID: PMC4970484.

4. Mandair D, Kamieniarz L, Pizanias M, et al. 2022; Diagnostic features and management options for duodenal neuroendocrine neoplasms: a retrospective, multi-centre study. Sci Rep. 12:15762. DOI: 10.1038/s41598-022-19738-9. PMID: 36130981. PMCID: PMC9492724.

5. Jung SW. 2021; Endoscopic treatment of gastric and duodenal neuroendocrine tumors: present and future. Korean J Helicobacter Up Gastrointest Res. 21:29–34. DOI: 10.7704/kjhugr.2020.0055.

6. Kim GH, Kim JI, Jeon SW, et al. 2014; Endoscopic resection for duodenal carcinoid tumors: a multicenter, retrospective study. J Gastroenterol Hepatol. 29:318–324. DOI: 10.1111/jgh.12390. PMID: 24117946.

7. Mahmud N, Tomizawa Y, Stashek K, Katona BW, Ginsberg GG, Metz DC. 2019; Endoscopic resection of duodenal carcinoid tumors: a single-center comparison between simple polypectomy and endoscopic mucosal resection. Pancreas. 48:60–65. DOI: 10.1097/MPA.0000000000001197. PMID: 30451799. PMCID: PMC6289751.

8. Bechara R, Ikeda H, Inoue H. 2015; Peroral endoscopic myotomy: an evolving treatment for achalasia. Nat Rev Gastroenterol Hepatol. 12:410–426. DOI: 10.1038/nrgastro.2015.87. PMID: 26035678.

9. Inoue H, Minami H, Kobayashi Y, et al. 2010; Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 42:265–271. DOI: 10.1055/s-0029-1244080. PMID: 20354937.

10. Khashab MA, Stein E, Clarke JO, et al. 2013; Gastric peroral endoscopic myotomy for refractory gastroparesis: first human endoscopic pyloromyotomy (with video). Gastrointest Endosc. 78:764–768. DOI: 10.1016/j.gie.2013.07.019. PMID: 24120337.

11. Liu W, Zeng XH, Yuan XL, et al. 2019; Open peroral endoscopic myotomy for the treatment of achalasia: a case series of 82 cases. Dis Esophagus. 32:1–7. DOI: 10.1093/dote/doz052. PMID: 31175357.

12. Lee WD, Song JS, Kim BS, et al. 2022; Safety and efficacy of prophylactic gastric open peroral endoscopic myotomy for prevention of post-ESD stenosis: a case series (with video). J Dig Dis. 23:220–227. DOI: 10.1111/1751-2980.13094. PMID: 35373499.