Preliminary experience of hybrid endoscopic submucosal dissection by duodenoscope for recurrent laterally spreading papillary lesions

Figure 1 Endoscopic and pathological characteristics of case 1. A-D: Hybrid endoscopic submucosal dissection (ESD) for recurrent, laterally spreading, duodenal papillary adenoma, including marks, submucosal injection and submucosal dissection. The lesion was resected completely using a polypectomy snare, and the artificial ulcer was visible; E: Endoscopic retrograde cholangiopancreatography (ERCP) showed the dilated biliary duct, common bile duct stones, and mildly dilated pancreatic duct; F: Biliary and pancreatic duct stents were implanted, and the endoscopic clips were used for closure of mucosal defects and prevention of complications; G: Hematoxylin and eosin stained resected specimen showing tubulovillous adenoma with a clean cutting edge, 4 ×; H: Endoscopic follow-up 3 mo after hybrid ESD, biliary stent and stones were extracted by ERCP; I: Histological follow-up of biopsy specimen revealed chronic and acute inflammation of small intestinal mucosa, 10 ×; J: Endoscopic follow-up 20 mo after hybrid ESD with no recurrence.

Figure 2 Endoscopic and pathological characteristics of case 2. A: Red and protuberant laterally spreading lesion was seen in the mucosa around the opening of the pancreaticobiliary duct; B-D: Hybrid endoscopic submucosal dissection (ESD) such as submucosal injection and submucosal dissection are shown, and the artificial ulcer was created; E and F: Endoscopic retrograde cholangiopancreatography showed the normal bile and pancreatic ducts, biliary and pancreatic stents were implanted, and close incision was performed by endoscopic clips; G: Hematoxylin and eosin-stained resected specimen showing tubulovillous adenoma with clean cutting edge, 4 ×; H: Endoscopic follow-up 3 mo after hybrid ESD showed that the pancreatic stent disappeared, and the biliary stent and clips were removed; I: Histological follow-up of biopsy specimen revealed chronic and acute inflammation of small intestinal mucosa, 20 ×; J: Endoscopic follow-up 38 mo after hybrid ESD with no recurrence.