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

Figure 3. Complete closure of a mucosal defect in a case with intraprocedural perforation: (A) a 5 mm perforation occurred during
submucosal dissection; (B) the wound was approximated by pulling the string tight to the clip; and (C) the whole mucosal defect was
completely closed. The post-procedural clinical course was uneventful, and the patient was discharged on Post-Procedural Day 4.

Figure 4. Endoscopic naso-biliary and naso-pancreatic drainage (ENBPD) in a case where complete closure was impossible: (A) ESD
completed for lesion located on the oral side of the main papilla; (B) complete closure was impossible because the main papilla was too
close to the mucosal defect; and (C) ENBPD tubes were inserted and the post-procedural clinical course was uneventful.

The situation is more complicated for delayed perforations that occur a long time after ESD. The tissue
surrounding the wound becomes fragile due to inflammation, and mechanical suturing is often impossible.
For such cases, drainage of the bile and pancreatic ducts using the ERCP technique has been reported to be
effective. We also reported cases with delayed perforation successfully managed by only endoscopic naso-
biliary and naso-pancreatic duct drainage that did not require any other invasive intervention . Although
[45]
post-ERCP pancreatitis was observed in 16% of cases, due to the high morbidity of surgical treatment, it can
be considered a salvage option for cases with delayed adverse event [Figure 4].

FUTURE PERSPECTIVE
Duodenal ESD is still a technically challenging procedure, and it is not recommended as a standard
treatment, considering its high morbidity. However, it has a great advantage of secure en bloc resection
irrespective of lesion size and location. Several recent studies have shown that protection of the post-ESD
wound could prevent delayed AE. A simpler and more reliable method for wound protection would
contribute to further improvement of the outcomes and widespread use of duodenal ESD in the future.
Moreover, the process to overcome difficulty of duodenal ESD through discovering unmet medical
demands would contribute to further advances of therapeutic endoscopy in any organ as well as duodenal
ESD.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis and
interpretation: Kato M