The endoscopic procedures were performed with a single-channel endoscope (GIF-Q240 or PCF-PQ260I; Olympus Medical Systems Co., Tokyo, Japan) or a double balloon sigmoid scope (EN-450T5/W; FUJIFILM, Saitama, Japan) by carbon dioxide insufflation. The choice of scope depended on the distance to the lesion.
EMR was indicated for small lesions (< 2 cm) or pedunculated lesions. Simple snarectomy was performed after the injection of 0.4% sodium hyaluronate solution (MucoUp; Johnson and Johnson K.K., Tokyo, Japan). The mucosa bulge is important for the safety of the procedure because the wall of the duodenum is thin. ESD was indicated for large lesions (≥ 2 cm) or flattened lesions. The ESD technique consisted of three steps. First, the periphery of the lesion was marked using a 2.0 mm short needle knife with a water jet function (Flush Knife, DK2618JB20; FUJIFILM, Saitama, Japan). Second, MucoUp was injected into the submucosal layer to achieve sufficient mucosal elevation. Third, a mucosal incision and submucosal dissection were performed with the Flush Knife (1.5 mm or 2.0 mm). Additionally, an electric current generator (VIO300D; ERBE, Tübingen, Germany) was used for hemostasis.
Prophylactic clipping using hemoclips (HX-110/610; Olympus Medical Systems Co.) was performed for mucosal defects after ER.
EMR was indicated for small lesions (< 2 cm) or pedunculated lesions. Simple snarectomy was performed after the injection of 0.4% sodium hyaluronate solution (MucoUp; Johnson and Johnson K.K., Tokyo, Japan). The mucosa bulge is important for the safety of the procedure because the wall of the duodenum is thin. ESD was indicated for large lesions (≥ 2 cm) or flattened lesions. The ESD technique consisted of three steps. First, the periphery of the lesion was marked using a 2.0 mm short needle knife with a water jet function (Flush Knife, DK2618JB20; FUJIFILM, Saitama, Japan). Second, MucoUp was injected into the submucosal layer to achieve sufficient mucosal elevation. Third, a mucosal incision and submucosal dissection were performed with the Flush Knife (1.5 mm or 2.0 mm). Additionally, an electric current generator (VIO300D; ERBE, Tübingen, Germany) was used for hemostasis.
Prophylactic clipping using hemoclips (HX-110/610; Olympus Medical Systems Co.) was performed for mucosal defects after ER.