document: although endoscopic resection can be a curative procedure for such lesions 1 , it still remains technically challenging because of the high risk of severe adverse events ( saes ) including delayed perforation 2 . on the other hand , surgical treatment of such lesions often results in extensive resections , causing significant morbidity . 
   recently , laparoscopic and/or endoscopic full - thickness resection ( ftr ) has been reported to be a useful technique for the treatment of nonampullary sdns 3 
   4 
   5 . despite their minimally invasive nature , all ftr procedures are associated with the possibility of intraperitoneal tumor dissemination . 
   therefore , we developed an alternative ftr method , which we call laparoscopy - assisted endoscopic full - thickness resection with ligation device ( laeftr - l ) . 
   herein we report on resection of nonampullary sdns using laeftr - l in 5 consecutive patients and an evaluation of the efficacy and safety of these procedures . 
   from june 2015 to september 2015 , 5 patients underwent resection of nonampullary sdns using laeftr - l . written informed consent 
   the set up for the laeftr - l procedure was previously described 3 . after mobilizing the duodenum from the retroperitoneum , a forward - viewing endoscope ( gif260j ; olympus , medical systems corp . , 
   tokyo , japan ) was inserted into the duodenum and the target lesion was identified ( fig . 
   endoscopic light was used to help the surgeon identify the tumor location . using an endoclip as a marker , 
   the tumor ( including the seromuscular layer ) was ligated using a ligation device ( pneumo - activate evl device ; sumitomo bakelite corp . , 
   the laparoscopist then temporarily sutured the seromuscular layer , after confirming the presence of a full - thickness aspirated sign ( fig . 
   then , an endoscopist resected the targeted lesion under the ligation band using snare technique ( fig . 
   2b ) . finally , the specimen was retrieved intraluminally using the endoscope ( fig . 
   despite the lack of a seromuscular layer , the provisional and additional sutures prevented exposure of the abdominal cavity to malignant cells . in addition , vessels were ligated during the closure of the defect in the duodenal wall . 
   therefore , the laeftr - l procedure was completed in a closed manner without complications . 
   endoscopic findings of laparoscopy - assisted endoscopic full - thickness resection with ligation device for superficial duodenal neoplasm . a a flat elevated lesion , measuring 15  mm in diameter , located at the opposite side of the ampulla of vater . 
   b using an endoclip as a marker , the targeted lesion was ligated with a ligation device . 
   e laparoscopic temporary suture secures patency of the duodenal wall . f resected lesion after administration of 0.1  % indigo carmine solution . 
   laparoscopic findings of laparoscopy - assisted endoscopic full - thickness resection with ligation device for superficial duodenal neoplasm 
   . a full - thickness aspirated sign , which helps the surgeon accurately identify the tumor location . 
   inhibitors of gastric acid and protease secretion were administered to the patients during their hospitalizations . 
   a normal diet was resumed approximately 2 days after the procedure , and the patients were discharged after a 1-week hospital stay . 
   from june 2015 to september 2015 , 5 patients underwent resection of nonampullary sdns using laeftr - l . written informed consent 
   the set up for the laeftr - l procedure was previously described 3 . after mobilizing the duodenum from the retroperitoneum , a forward - viewing endoscope ( gif260j ; olympus , medical systems corp . , 
   tokyo , japan ) was inserted into the duodenum and the target lesion was identified ( fig . 
   endoscopic light was used to help the surgeon identify the tumor location . using an endoclip as a marker , 
   the tumor ( including the seromuscular layer ) was ligated using a ligation device ( pneumo - activate evl device ; sumitomo bakelite corp . , ltd . 
   the laparoscopist then temporarily sutured the seromuscular layer , after confirming the presence of a full - thickness aspirated sign ( fig . 
   then , an endoscopist resected the targeted lesion under the ligation band using snare technique ( fig .  1c , fig . 
   2b ) . finally , the specimen was retrieved intraluminally using the endoscope ( fig . 
   despite the lack of a seromuscular layer , the provisional and additional sutures prevented exposure of the abdominal cavity to malignant cells . in addition , vessels were ligated during the closure of the defect in the duodenal wall . 
   therefore , the laeftr - l procedure was completed in a closed manner without complications . 
   endoscopic findings of laparoscopy - assisted endoscopic full - thickness resection with ligation device for superficial duodenal neoplasm . a a flat elevated lesion , measuring 15  mm in diameter , located at the opposite side of the ampulla of vater . 
   b using an endoclip as a marker , the targeted lesion was ligated with a ligation device . 
   e laparoscopic temporary suture secures patency of the duodenal wall . f resected lesion after administration of 0.1  % indigo carmine solution . 
   laparoscopic findings of laparoscopy - assisted endoscopic full - thickness resection with ligation device for superficial duodenal neoplasm . 
   a full - thickness aspirated sign , which helps the surgeon accurately identify the tumor location . 
   inhibitors of gastric acid and protease secretion were administered to the patients during their hospitalizations . 
   a normal diet was resumed approximately 2 days after the procedure , and the patients were discharged after a 1-week hospital stay . 
   two of the 5 tumors were located at the duodenal bulb , and the others at the second part of the duodenum ( opposite to the ampulla of vater ) . 
   the mean operative time was 173 minutes ( range 138    217 minutes ) . 
   mean diameter of the resected specimen was 24  mm ( range 18    32  mm ) , and the mean tumor size was 9  mm ( range 7    11  mm ) . 
   complete resection was achieved , and full - thickness resection was histologically confirmed in all cases ( fig . 
   because the malignant potential of sdn is difficult to define from the preoperative endoscopic diagnosis 6 , complete en - bloc resection is necessary to achieve appropriate pathological evaluation and treatment . 
   although conventional endoscopic mucosal resection ( emr ) could be a curative strategy for sdns , complete resection is challenging , especially for flat or non - lifting lesions . in recent years , the indications for esd 
   however , delayed perforation in the duodenum , in particular , may cause potentially fatal peritonitis or retroperitoneal complications , requiring emergency open surgery to counter leakage of bile and pancreatic juices 8 . 
   moreover the technical difficulty of this procedure is extremely high , due to the poor maneuverability of the endoscope and the thin wall . 
   therefore , duodenal esd is not a standard clinical procedure . on the other hand , 
   although short - term clinical outcomes were preferable , we need to consider the risk of intraperitoneal tumor dissemination , given the lack of data on long - term outcomes in patients undergoing conventional ftr procedures . compared with conventional ftr procedures , laeftr - l has two advantages . 
   most importantly , the resected specimen can be collected intraluminally , avoiding contact with the peritoneum . 
   shen et al . conducted an animal model study and revealed that pneumoperitoneum from laparoscopic surgery could be a risk factor for peritoneal dissemination of tumor cells 9 . 
   because long - term outcomes of sdns treated with the conventional ftr method rarely have been investigated , peritoneal exposure of tumor cells should be avoided as far as possible . moreover , laeftr - l does not require proficient experience in esd . 
   indeed , total operative time was not different from previous reports on conventional ftr for sdns 3 
   4 , and endoscopic resection time was even significantly shorter . 
   tumor size is a major limiting factor when considering the indication for laeftr . in the current study , 
   reported that esophageal subepithelial lesions no larger than 13  mm could be successfully resected by emr with a ligation device 10 . 
   considering the size of the ligation device , lesions smaller than 15  mm in diameter may be candidates for this procedure . 
   although additional studies are needed , application of a large oblique cap may enable en - bloc resection of larger lesions . 
   in addition , tumor location is also important to decisions about the indication for laeftr - l . 
   laeftr - l can not to be applied to lesions close to the ampulla of vater , because mobilization of these portions is technically difficult with laparoscopic procedures 
   . in conclusion , laeftr - l may be a promising technique for the treatment of nonampullary sdns which can achieve complete resection without peritoneal exposure of tumor cells or saes . 
   prospective studies are needed to further evaluate the efficacy and safety of laeftr - l procedures .
summary: background and study aims : recently , laparoscopic and/or endoscopic full - thickness resection ( ftr ) has been reported to be a useful technique for the treatment of superficial duodenal neoplasms ( sdns ) . in the current study , we evaluated clinical outcomes in 5 consecutive patients who underwent resection of nonampullary sdns using laparoscopy - assisted endoscopic full - thickness resection with ligation device ( laeftr - l ) , which is an alternative ftr method developed to avoid peritoneal dissemination . using a snare technique with a ligation band 
   , the duodenal lesions were easily resected . 
   the provisional and additional sutures for the resected site prevented delayed perforation and bleeding and they also protected the abdominal cavity from direct exposure to malignant cells . 
   complete resection could be achieved and ftr was histologically confirmed in all cases . 
   the mean operation time was 173 minutes ( range 138 
   217 minutes ) . 
   mean diameter of the resected specimen was 24  mm ( range 18    32  mm ) . 
   no adverse events ( aes ) were observed . 
   laeftr - l , which can achieve complete resection of nonampullary sdns without severe aes and peritoneal dissemination , could be a useful technique for the treatment of such lesions .