Ischemic treatment of the duodenal windsock web using the ultra-thin endoscope, with modified detachable snares

Abstract

Figures

Computed tomography revealed a diverticulum in the second portion of the duodenum.

Endoscopic findings. a EGD from the oral side reveals a duodenal diverticulum and orifice similar to a pinhole. The orifice is located at the entrance of the true lumen. b EGD from the anal side reveals a web structuring the diverticulum. The papilla of Vater is found near the web. Abbreviation: EGD, esophagogastroduodenoscopy.

Full text

A duodenal web, one of the causes of congenital duodenal obstruction, is a rare congenital anomaly 1 . Patients with a complete-type duodenal web exhibit duodenal obstruction early in infancy, whereas those with a fenestrated type may be diagnosed with obstruction in adulthood 2 . In addition, peristalsis and gravity of food can cause the web to balloon distally, taking on the form of a windsock 3 . This forms a duodenal intraluminal diverticulum.

Endoscopic treatment of the duodenal web has become feasible in recent years; however, recurrence and adverse events, including bleeding, are concerning 1 3 4 .

A 27-year-old woman had experienced occasional vomiting attacks after eating since childhood. She was suspected to have an intraluminal duodenal diverticulum on computed tomography ( Fig. 1 ) and was diagnosed with a duodenal windsock web on esophagogastroduodenoscopy ( Fig. 2 a,b ).

Computed tomography revealed a diverticulum in the second portion of the duodenum.

Endoscopic findings. a EGD from the oral side reveals a duodenal diverticulum and orifice similar to a pinhole. The orifice is located at the entrance of the true lumen. b EGD from the anal side reveals a web structuring the diverticulum. The papilla of Vater is found near the web. Abbreviation: EGD, esophagogastroduodenoscopy.

An ultra-thin endoscope (EG-530NW, Fujifilm) was passed through the narrow entrance of the true lumen ( Video 1 ). After confirming the location of the duodenal papilla in the reflex position, we tightened the neck of the web from the anal side using a detachable snare (HX-400U-30, Olympus) with the sheath removed to induce the web ischemia 5 . Two days later, the residual mucosa of the web near the necrotic area was tightened using a detachable snare. The following day, the web became entirely necrotic. We cut and removed the snares, made a new entrance to the lumen by penetrating the necrotic mucosa using forceps and scope, and then detained the clips at the side of the entrance. The patient’s abdominal bloating improved postoperatively. The new entrance was kept open, and the contrast medium was passed through the lumen without delay. The patient had no adverse events or recurrences. In conclusion, ischemic treatment in the reflex position is safe for duodenal webs.

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Case presentation of ischemic treatment for the duodenal windsock web.Video 1