A 67-year-old man with MUTYH-associated polyposis underwent an en bloc endoscopic mucosal resection (EMR) of a 20mm non-granular laterally spreading tumor, type 0-IIa of the Paris classification, in the duodenum, distally to the ampulla region (Fig. 1).
After resection, a “target sign” was observed (Figs. 2 and 3). The defect was closed by endoscopic clipping using five clips in a zipper fashion and a nasojejunal feeding tube was placed distally to the EMR region.
Postprocedure abdominal CT with contrast showed a thin layer of retroperitoneal free air, but no contrast extravasation was observed. The patient was managed conservatively and discharged four days later, completely asymptomatic.
EMR for the duodenum carries a high risk of perforation, due to the thin muscle layer in this region, compared with the remaining digestive tract. Generally, the risk for perforation is higher in large lesions (>20mm)1. Early diagnosis of perforation can be made by careful analysis of the post-EMR specimen which may reveal a “target sign”, a marker of resection of the muscularis propria and imminent perforation. Colonic target sign is common, but it is rare in the duodenum2.
Recognition of this sign allows endoscopic management instead of surgery, with a shorter hospital stay and fewer adverse events.
Conflict of interestsNone of the authors has any financial/conflicting interests to disclose.
