Uploaded July 2017 | Updated September 2026, 15 hours ago
This video illustrated how to access a difficult ileocecal valve with the help of a biopsy forceps.
This video illustrated how to access a difficult ileocecal valve with the help of a biopsy forceps.







![Duodenal ESD for a recurrent adenoma: combining SITE, traction, and hook–drag–cut dissection
Text
Endoscopic submucosal dissection (ESD) in the duodenum is widely considered the most challenging ESD procedure and should be performed only in high-volume centers due to the thin wall and substantial risk of perforation, particularly in the presence of fibrosis following prior interventions [1,2]. We present a combined strategy using undersaline immersion technique, countertraction and hook-drug-cut dissection technique for the safe resection of a recurrent non-ampullary duodenal adenoma (Video 1).
A 70-year-old woman was referred with a 1.5-cm recurrent adenoma located in the second portion of the duodenum after multiple previous polypectomy attempts. Given the significant fibrosis, ESD was selected and performed under general anesthesia with surgical backup. The lumen was filled with normal saline to create an undersaline environment, and lesion margins were carefully delineated using a needle-type knife in forced coagulation mode. A circumferential mucosal incision was followed by the creation of a lateral mucosal flap to facilitate access to the submucosal space (Fig. 1).
Clip-and-band traction was applied to improve exposure and maintain tension on the dissection plane (Fig. 2), as previously described [4]. Submucosal dissection was performed using a water-jet knife connected to a pump, allowing continuous injection and precise cutting. The saline environment provided magnified visualization, minimized electrosurgical smoke, and enhanced identification of submucosal fibers, which is particularly useful in fibrotic lesions [2,4]. In fibrotic areas, careful hook-and-drag movements were performed while maintaining a dissection plane parallel to the muscularis propria to reduce the risk of perforation (Fig 3-5).
En bloc resection was achieved without intraprocedural or delayed adverse events. The resection site was completely closed using endoscopic clips, in accordance with current recommendations [2]. The patient had an uneventful recovery and was discharged without complications. This combined approach may improve safety and efficacy in selected cases of duodenal ESD with significant fibrosis.
Mavrogenis et al. Endoscopy 2026. Duodenal ESD for a recurrent adenoma: combining SITE, traction, and hook–drag–cut dissection](https://i.ytimg.com/vi/SG8tpjV4iCc/mqdefault.jpg)


