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case_images: Upper gastrointestinal endoscopy and abdominal plain CT findings. (a) Upper gastrointestinal endoscopy showing the elevated lesion (10 mm in diameter) at the opposite side of the ampulla of Vater. (b) CT showing the transplanted liver very close to the transverse colon (axial image).
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case_images: Upper gastrointestinal endoscopy revealed a high-grade adenoma by biopsy, 15 mm in diameter, on the opposite side of the ampulla of Vater (Fig. 1a), and we decided to perform D-LECS. Preoperative computed tomography (CT) revealed no metastasis to any other organs but that the transplanted liver was very close to the transverse colon (Fig. 1b).
case_images: Intraoperative findings before ESD. (a) The liver adheres to the upper abdominal wall and transverse colon as expected (arrow). (b) The transvers mesentery is dissected. (c) There is strong adhesion around the duodenal bulb because of the previous surgery (arrow). (d) An adequate space around the tumor at the second portion of the duodenum is made.
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case_images: Intraoperatively, the liver adhered to the upper abdominal wall and transverse colon as expected (Fig. 2a). When the transverse mesentery was dissected to avoid injury to the colonic vessels (Fig. 2b), the second portion of the duodenum was approached, where strong adhesions were observed (Fig. 2c). An adequate space was created around the tumor (Fig. 2d).
case_images: ESD was performed. (a) Before dissection. (b) After dissection. (c) The resected specimen.
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case_images: Next, ESD was performed (Fig. 3a and b), and the resected specimen was retrieved orally. Microscopically, the resected specimen was a high-grade tubular adenoma with negative surgical margins (Fig. 3c).
case_images: Intraoperative findings after ESD. (a) The seromuscular layer of the mucosal defect lesion is sutured laparoscopically to reinforce it. (b) After confirming sufficient reinforcement of the defect and no bleeding nor passage obstruction by both upper gastrointestinal endoscopy and laparoscopy, the transverse colon mesentery is closed to finish the operation.
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case_images: Next, the seromuscular layer of the mucosal defect lesion was sutured laparoscopically to reinforce it because it was endoscopically difficult to close the mucosal defect at the post-ESD site (Fig. 4a). After confirming sufficient reinforcement of the defect and no bleeding nor passage obstruction by both upper gastrointestinal endoscopy and laparoscopy, the transverse colon mesentery was closed to finish the operation (Fig. 4b).