title: "Underwater" EMR of sporadic laterally spreading nonampullary duodenal adenomas (with video).
abstract: BACKGROUND
  EMR for the treatment of duodenal adenomas is challenging due to a thin wall and rich vascularity.
  
  
  OBJECTIVE
  To evaluate a novel technique of "underwater" EMR without prior submucosal injection for the removal of large (≥2 cm) laterally spreading nonampullary duodenal adenomas.
  
  
  METHODS
  Prospective, observational study.
  
  
  METHODS
  Tertiary academic referral center.
  
  
  METHODS
  Twelve patients (median age, 60 years) meeting the inclusion criteria.
  
  
  METHODS
  Piecemeal EMR technique after sterile water submersion when using a double-channel endoscope.
  
  
  METHODS
  Technical success, adverse events, completeness of resection on follow-up endoscopy.
  
  
  RESULTS
  Median adenoma size was 35 mm (25% greater than one-half circumference, 50% equal to one-third to one-half circumference, and 25% less than one-third circumference). Median procedure time was 65 minutes (range, 32-151). Final histology was tubular adenoma (7), tubulovillous adenoma (1), villous adenoma (3), and high-grade dysplasia (1). Eleven patients (92%) met the primary endpoint (technical success) and all patients met the secondary endpoint (completeness of resection). Median interval until follow-up endoscopy was 16 weeks (range, 11-56). Adverse events were as follows: delayed bleeding (3 patients, of whom 2 required transfusions), water intoxication syndrome manifested by altered mental status and hyponatremia (1), and stricture formation (1) that responded to balloon dilation. No perforation or postresection abdominal pain was found.
  
  
  CONCLUSIONS
  Single operator, single center, small sample size, limited follow-up.
  
  
  CONCLUSIONS
  Underwater EMR for large sessile duodenal adenomas has high success rates for complete removal. The risk of delayed bleeding is significant, and precautions are needed when infusing a large volume of fluid into the GI tract.
authors: Paul May & Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California 94115, USA.
authors: Kenneth F
authors: KF
authors: Binmoeller
authors: Janak N
authors: JN
authors: Shah
authors: Yasser M
authors: YM
authors: Bhat
authors: Steve D
authors: SD
authors: Kane
mesh_terms: D018253:Adenoma, Villous / Q000473:pathology / Q000601:surgery*; D000328:Adult; D000368:Aged; D003251:Constriction, Pathologic / Q000209:etiology; D004379:Duodenal Neoplasms / Q000473:pathology / Q000601:surgery*; D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology*; D006801:Humans; D007413:Intestinal Mucosa / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D019106:Postoperative Hemorrhage / Q000209:etiology*; D011446:Prospective Studies; D014867:Water / Q000008:administration & dosage / Q000009:adverse effects; D014869:Water Intoxication / Q000209:etiology
chemical_list: D014867:Water
keywords: HD; NBI; UEMR; high definition; narrow-band imaging; underwater EMR