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Kato et al. Mini-invasive Surg 2022;6:10 https://dx.doi.org/10.20517/2574-1225.2021.124 Page 5 of 8

Figure 2. The string clip suturing method for a large mucosal defect: (A) a 40 mm flat elevated lesion was found in the descending
duodenum; (B, C) the wound was approximated by pulling the string tight to the clip; (D, E) the string was cut by forceps and additional
clips were deployed; and (F) the wound was completely closed.

Although wound protection is effective for the prevention of delayed AE after duodenal ESD, there are
some remaining issues. Devices and materials for protection are expensive: an OTSC costs about $700, a
PGA sheet costs about $140, and the fibrin glue costs about $300. Moreover, the fibrin glue is derived from
donated blood, which has a low but non-negligible risk of AE such as infection. The string-clip suturing
method is cheap, but it demands endoscopists’ skill. Mizutani et al. explored the predictors for difficulty
[41]
of closure and concluded that the tumor location of medial/anterior wall and lesion size more than 40 mm
are risk factors for incomplete closure.

Another way to prevent delayed AE is suturing the wound from the peritoneal side by laparoscopy
assistance in addition to flexible endoscopy from inside the duodenum lumen. This novel surgical
[42]
procedure, named endoscopic cooperative surgery (D-LECS), was first reported in 2015 . A retrospective
case series with 206 cases undergoing D-LECS revealed 95% R0 resection rate, 1.5% perforation rate, and 1%
bleeding rate, suggesting favorable outcomes . D-LECS has been covered by health insurance in Japan
[43]
since April 2021.

COUNTERMEASURES FOR COMPLICATIONS
As mentioned above, various preventive measures can significantly reduce the risk of delayed AE after
duodenal ESD; unfortunately, it is difficult to prevent them completely. Therefore, it is also important to
know how to manage delayed AEs. The management of perforation is particularly important because it
sometimes requires highly invasive treatment including surgery.

We analyzed clinical courses of cases with perforation of duodenal ESD and found that closing the whole
area of mucosal defect as well as perforation site improved clinical outcomes. The maximum C-reactive
protein value and length of hospital stay of cases where the mucosal defect was closed completely were
almost equivalent to those without perforation . Closing the mucosal defect enables managing the patients
[44]
conservatively in the case of intraprocedural perforation as well as helps avoid delayed AE [Figure 3].