Advertisement

Endoscopic submucosal dissection with reinforcement using a laparoscopic approach for a duodenal cavernous hemangioma

Open AccessPublished:September 18, 2022DOI:https://doi.org/10.1016/j.vgie.2022.07.009

      Video

      (mp4, (70.63 MB)

      Endoscopic submucosal dissection with reinforcement using a laparoscopic approach (duodenal-laparoscopic and endoscopic coordinated surgery with endoscopic submucosal dissection) for a duodenal cavernous hemangioma. The mucosal defect was reinforced with laparoscopic seromuscular sutures after duodenal endoscopic submucosal dissection was performed.

      Abbreviations:

      ESD (endoscopic submucosal dissection), D-LECS (duodenal-laparoscopic and endoscopic coordinated surgery)
      Duodenal cavernous hemangiomas are rare; however, when they occur, they may require hemostasis.
      • Nishiyama N.
      • Mori H.
      • Kobara H.
      • et al.
      Bleeding duodenal hemangioma: morphological changes and endoscopic mucosal resection.
      Hemangiomas are classified into cavernous, capillary, or mixed tumors; the cavernous type is the most common.
      • Regula J.
      • Wronska E.
      • Pachlewski J.
      Vascular lesions of the gastrointestinal tract.
      Cavernous hemangiomas are defined as congenital benign vascular lesions that are venous malformations. Because cavernous hemangiomas are derived from the submucosa, even minimally invasive endoscopic procedures—such as polyp resection, endoscopic mucosal resection, and argon plasma coagulation—may cause heavy bleeding or perforation. In this case, we did not opt for endoscopic mucosal resection using band ligation because the lesion size was slightly larger than 1 cm, making it too large for ligation. Endoscopic submucosal dissection (ESD), a highly invasive endoscopic procedure, has been reported to have a high adverse event rate for duodenal lesions.
      • Nonaka S.
      • Oda I.
      • Tada K.
      • et al.
      Clinical outcome of endoscopic resection for nonampullary duodenal tumors.
      Although laparoscopic resection is reportedly useful for duodenal lesions,
      • Orsenigo E.
      • Di Palo S.
      • Vignali A.
      • et al.
      Laparoscopic excision of duodenal schwannoma.
      it is highly invasive and associated with a difficulty in identifying the exact tumor location. Here, we performed ESD with reinforcement using a laparoscopic approach (duodenal-laparoscopic and endoscopic coordinated surgery [D-LECS] with ESD) for a duodenal cavernous hemangioma (Video 1, available online at www.giejournal.org), which was previously reported to facilitate postexcisional suturing and reduce the risk of perforation.
      • Nunobe S.
      • Ri M.
      • Yamazaki K.
      • et al.
      Safety and feasibility of laparoscopic and endoscopic cooperative surgery for duodenal neoplasms: a retrospective multicenter study.
      ,
      • Irino T.
      • Nunobe S.
      • Hiki N.
      • et al.
      Laparoscopic-endoscopic cooperative surgery for duodenal tumors: a unique procedure that helps ensure the safety of endoscopic submucosal dissection.
      A 75-year-old man was hospitalized for iron deficiency anemia. Single-balloon enteroscopy revealed a 12 mm reddish tumor in the third portion of the duodenum near the ligament of Treitz, suggestive of a cavernous hemangioma (Fig. 1). Following capsule endoscopy, this lesion was discerned as the cause of the anemia (Fig. 2).
      Figure thumbnail gr1
      Figure 1Endoscopic image of a cavernous hemangioma in the third portion of the duodenum.
      Figure thumbnail gr2
      Figure 2Based on the findings of capsule endoscopy, this lesion was discerned as the cause of the patient’s anemia. Enteroscopy was performed before the capsule endoscope, and a marking clip was placed near the tumor at that time. The clip is shown in the capsule endoscopy image.
      D-LECS with ESD was performed with the patient under general anesthesia using colonoscopy. After injecting hyaluronic acid into the submucosa, ESD was performed using a Flush Knife BT-S (Fujifilm, Tokyo, Japan) while coagulating the abundant, dilated blood vessels via the coagulation mode with incision (Fig. 3). The mucosal defect was reinforced with laparoscopic seromuscular sutures after ESD. The site at the end duodenal luminal patency was confirmed (Fig. 4). The histopathological diagnosis was that of a cavernous hemangioma (12 × 10 mm), which was observed at 20× magnification using hematoxylin and eosin staining (Fig. 5). The patient was discharged without any adverse events; thus, D-LECS with ESD may be useful for the management of this disease. We are not aware of another report of D-LECS with ESD for a duodenal cavernous hemangioma.
      Figure thumbnail gr3
      Figure 3Endoscopic submucosal dissection was performed while coagulating the dilated vessels with coagulation mode.
      Figure thumbnail gr4
      Figure 4Video image. A, Laparoscopic image from outside the lumen of the duodenum. B, The site at the end duodenal luminal patency was confirmed.
      Figure thumbnail gr5
      Figure 5A, B, The macroscopic specimen and histopathological diagnosis were that of cavernous hemangioma (12 × 10 mm), which was observed at 20× magnification using hematoxylin and eosin staining.

      Disclosure

      All authors disclosed no financial relationships.

      Ethics Statement

      This retrospective study was performed according to the Declaration of Helsinki, and written informed consent was obtained from the patient.

      Supplementary data

      References

        • Nishiyama N.
        • Mori H.
        • Kobara H.
        • et al.
        Bleeding duodenal hemangioma: morphological changes and endoscopic mucosal resection.
        World J Gastroenterol. 2012; 18: 2872-2876
        • Regula J.
        • Wronska E.
        • Pachlewski J.
        Vascular lesions of the gastrointestinal tract.
        Best Pract Res Clin Gastroenterol. 2008; 22: 313-328
        • Nonaka S.
        • Oda I.
        • Tada K.
        • et al.
        Clinical outcome of endoscopic resection for nonampullary duodenal tumors.
        Endoscopy. 2015; 47: 129-135
        • Orsenigo E.
        • Di Palo S.
        • Vignali A.
        • et al.
        Laparoscopic excision of duodenal schwannoma.
        Surg Endosc. 2007; 21: 1454-1456
        • Nunobe S.
        • Ri M.
        • Yamazaki K.
        • et al.
        Safety and feasibility of laparoscopic and endoscopic cooperative surgery for duodenal neoplasms: a retrospective multicenter study.
        Endoscopy. 2021; 53: 1065-1068
        • Irino T.
        • Nunobe S.
        • Hiki N.
        • et al.
        Laparoscopic-endoscopic cooperative surgery for duodenal tumors: a unique procedure that helps ensure the safety of endoscopic submucosal dissection.
        Endoscopy. 2015; 47: 349-351