Early gastric cancer with ball valve syndrome treated by endoscopic submucosal dissection

An 84-year-old woman with pneumonia, congestive heart failure and chronic renal failure presented for iron-deficiency anemia and appetite loss. Esophagogastroduodenoscopy revealed a 60-mm sub-pedunculated tumor arising from the antrum of the stomach. The tumor was friable, with bleeding, and prolapsed into the duodenal bulb, the ball valve syndrome. The tumor was considered the cause of the anemia and appetite loss. Attempted endoscopic reduction of the prolapsing tumor was unsuccessful, but the base of its stalk could be identified through the transparent hood; thus, we removed the tumor with endoscopic submucosal dissection. The tumor was retrieved successfully, and pathohistological examination revealed the tumor to be a well-differentiated adenocarcinoma. This case suggests that endoscopic submucosal dissection is useful as an alternative to surgery for removal of gastric tumors that have prolapsed into the duodenal bulb when polypectomy was difficult, but provided the tumor's attachment site can be identified endoscopically.