Technical tips and pitfalls of duodenal endoscopic submucosal dissection

Since superficial non-ampullary duodenal epithelial tumor (SNADET) is a rare disease, the chance of performing endoscopic resection of a SNADET is relatively low. Duodenal endoscopic submucosal dissection (ESD) is extremely challenging and risky due to poor maneuverability of the endoscope and the thin duodenal muscle layer. Therefore, the treatment strategy should be made after carefully checking characteristics of the lesions and maneuverability of the endoscope as well as skills of the operator. Although ESD is very difficult to perform in the duodenum due to difficulties in opening the submucosal space, the Water Pressure Method allows us to perform a steady procedure. Secure closure of the resection bed is mandatory to avoid serious complications, and the String Clip Suturing Method enables secure closure even for a large resection bed. In case of a difficult situation in suturing, external drainage by an endoscopic naso-biliary and pancreatic drainage (ENBPD) tube is known to be extremely useful. Duodenal ESD is a very challenging procedure; however, the number of large duodenal lesions that require ESD is limited. Therefore, duodenal ESD should be centralized to leading institutions to acquire a good clinical outcome.