EMR of large periampullary neuroendocrine tumor

A 74-year-old man with a history of hypertension, chronic kidney disease, and diabetes mellitus type 2 presented with a 2-day history of melena. His hemoglobin level remained unchanged during hospitalization. He underwent an upper endoscopy that showed a 2to 3-cm periampullary mass (Fig. 1A) concerning for malignancy just distal to the ampulla (Figs. 1B and C). Examination of initial pinch biopsy specimens showed negative results. Subsequent EUS showed a 21by 11-mm mass that was mucosal in origin without invasion through the muscularis propria. Examination of core biopsy specimens revealed a neuroendocrine (carcinoid) tumor. The patient was referred to surgery; however, he declined surgical intervention and requested attempts for endoscopic removal. He underwent upper endoscopy under general anesthesia with a plan for EMR (Video 1, available online at www.VideoGIE.org). Injection of 5 mL of epinephrine (1:20,000) was performed in and around the tumor, and a large hexagonal snare was used to remove the tumor in 1 piece with the use of 30 W set to