Endoscopic treatment of a duodenal invagination.

A 47-year-old man was referred to North Hospital with a 2-month history of recurrent occlusive syndrome. Findings on computed tomography scan (●" Fig.1) and endoscopy led to a diagnosis of duodenal invagination and partial duodenal atresia. Endoscopic therapy was performed (●" Video 1). In the first endoscopic step (●" Fig.2), two 12/6t over-the-scope clips (OTSC; Ovesco AG, Tübingen, Germany) were deployed within the invagination in order to induce necrosis of the mucosa and fibrosis of the submucosa. A fully covered metallic stent 12×2cm (TaeWoong, Gyeonggi-do, South Korea) was placed from the bulb to the third duodenal portion, and fixed with two clips (Instinct; Cook, Bloomington, USA). In the second step 6 weeks later, the stent was retrieved, and migration of the OTSCs was confirmed. Necrosis of the duodenal foldswas also apparent. Amucosal protrusion remained, affecting one-third of the duodenal circumference. Thus, an endoscopic mucosectomy was performed (the mucosawas found to be histpathologically normal) (●" Fig.3). A new similar metallic stent was inserted and fixed in place with clips. In the third and final procedure 8 weeks after the previous step, the stent was removed and an inflammatory area was dilated using an 18–20mm controlled radial expansion balloon (CRE; Boston Scientific, Marlborough, USA). A mucosectomy of an invaginated growth involving one-quarter of the circumference of the second duodenal portion completed the procedure (●" Fig.4), resulting in complete patency of the duodenal lumen. At 3-month follow-up, symptom remission had been achieved: the patient had not suffered new occlusive episodes, had not required emergency department admission, and had no abdominal distension.