P-CAB achieved rapid artificial ulcer healing with promotion of granulation tissue formation. However, conventional PPI with initial intravenous infusion might be sufficient for prevention of postoperative bleeding following gastric ESD.
Brunner's glands are mucosal and submucosal alkalinesecreting glands that are most commonly located in the duodenum, especially in the first part of the duodenum, although they are rarely found in the pylorus and jejunum. Hyperplasia of these glands is normally seen in 2% of upper gastrointestinal (GI) endoscopies [1]. Five percent to 10% of benign duodenal tumors are caused by lesions of Brunner's gland [2]. They are usually asymptomatic and lesions are discovered incidentally but they can occasionally cause symptoms such as GI hemorrhage and obstruction when they reach sizes >2 cm [3,4]. In this paper, we report a case of large hyperplasia of Brunner's gland successfully treated by modified endoscopic submucosal dissection (ESD) technique.
Case reportA 33-year-old woman presented with a 1.5-year history of abdominal and back pain after meals. She had been prescribed medicines at another clinic, with the diagnosis of chronic pancreatitis. Because her symptoms did not improve, she was consulted at our department. On the same day, upper endoscopy was performed and showed a pedunculated torose lesion occupying the lumen of the duodenal cap. Biopsy specimens of the lesion showed only regenerative duodenal epithelium with mixed inflammatory cellular infiltrate, with no evidence of malignancy. The patient was hospitalized for close examination and treatment.The familial history was not contributory. She had no history of concern. Her physical status was moderate, and nutrition was good. Anemia was not observed in the palpebral conjunctivae, and jaundice was not observed in the bulbar conjunctivae. There were no abnormal physical findings in the thoracic or abdominal region (no hepatosplenomegaly or peripheral lymphadenopathy).Blood cell count and chemistry studies showed normal results. Carcinoembryonic antigen and cancer antigen19-9 were not elevated. Contrast-enhanced computed tomography (CT) of the abdominal region revealed a mass lesion in the first part of the duodenum. There was no invasion and the lesion was of the intraluminal type. Magnetic resonance cholangiopancreatography (MRCP) showed no abnormality, invasion, or dilatation in either the bile duct or the pancreatic duct.After informed consent, endoscopic treatment was performed for diagnosis at the patient's request. Modified ESD method (we used snare and grasping forceps and resected with electric current after all surrounding dissection of the lesion) was applied for this case. Resection was successful, without complications such as hemorrhage and perforation.The size of the resected specimen was 65 × 40 × 40 mm (Fig. 1). Macroscopically, soft and elastic tissue with shallow white lobulated lesions was observed. Microscopically, the lesion was composed of Brunner's glands, infiltrating the submucosa (Fig. 2). The lesion contained a dilative excretory duct, inflammatory cells, mainly lymphocytes, and an organoid structure with fibrosis (Fig. 3). There was no evidence of malignancy. The lesion was completely resected.After ESD, there were no complications...
This single-center retrospective study indicated that ESD-induced artificial ulcer healing was affected by submucosal fibrosis and injury of the proper muscle layer, which induced damage to the muscle layer. Therefore, the preferable pharmacotherapy can be determined on completion of the ESD procedure.
Background/Aims: Intraoperative bleeding remains a challenge during endoscopic submucosal dissection (ESD). Forceps-coagulated cut (FCC) was found to be effective to reduce this bleeding. However, this involved frequent device replacement, and therefore, knife-coagulated cut (KCC) might ensure an easier and smoother procedure. We aimed to assess the effectiveness of KCC with Flushknife-BT at a super-low-output setting. Methods: In this prospective study, we compared the hemostasis condition during ESD in 40 pairs of gastric lesions treated by FCC (Group F) or KCC (Group K). The primary outcome was frequency of major bleeding with an analysis by tumor location. The secondary outcomes included frequency of exchanging devices, procedure time, en bloc resection rate, and adverse event rate. Results: In terms of the frequency of major bleeding, there was no significant difference between Group F and K (0.95 ± 0.12 vs. 0.88 ± 0.17, p = 0.282). Lesions located on the upper third of the stomach involved repeated hemostasis (p = 0.012). The frequency of exchanging devices was higher in Group F than in Group K (6.95 ± 0.42 vs. 0.88 ± 0.17, p = 0.000). Procedure time was reduced in Group K by 15.6%. Other aspects were the same in both groups. Conclusion: KCC prevented intraoperative bleeding just as FCC did. But it decreased device replacement and saved time and only a low risk was involved. This technique could ensure the conduct of a smooth and safe procedure during gastric ESD. UMIN000017229.
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