Safety and efficacy of surgical and endoscopic resection in the treatment of duodenal subepithelial lesions

Giant Brunner's gland hyperplasia of the duodenum successfully resected en bloc by endoscopic mucosal resection: A case report

BACKGROUND

Duodenal Brunner's gland hyperplasia (BGH) is a therapeutic target when complications such as bleeding or gastrointestinal obstruction occur or when malignancy cannot be ruled out. Herein, we present a case of large BGH treated with endoscopic mucosal resection (EMR).

CASE SUMMARY

An 83-year-old woman presented at our hospital with dizziness. Blood tests revealed severe anemia, esophagogastroduodenoscopy showed a 6.5 cm lesion protruding from the anterior wall of the duodenal bulb, and biopsy revealed the presence of glandular epithelium. Endoscopic ultrasonography (EUS) demonstrated relatively high echogenicity with a cystic component. The muscularis propria was slightly elevated at the base of the lesion. EMR was performed without complications. The formalin-fixed lesion size was 6 cm × 3.5 cm × 3 cm, showing nodular proliferation of non-dysplastic Brunner's glands compartmentalized by fibrous septa, confirming the diagnosis of BGH. Reports of EMR or hot snare polypectomy are rare for duodenal BGH > 6 cm. In this case, the choice of EMR was made by obtaining information on the base of the lesion as well as on the internal characteristics through EUS.

CONCLUSION

Large duodenal lesions with good endoscopic maneuverability and no evident muscular layer involvement on EUS may be resectable via EMR.

Risk factors for complications and incomplete resection after endoscopic resection for duodenal submucosal tumors

BACKGROUND AND AIM

Endoscopic resection (ER) has been used to remove submucosal tumors (SMTs) in recent years; however, duodenal ER is associated with high rates of immediate or delayed bleeding and perforation. Whether ER can be recommended for the treatment of duodenal SMTs remains controversial. Therefore, we aimed to investigate the clinical outcomes associated with the ER of duodenal SMTs and to assess possible predictive factors for complications and incomplete resection.

METHODS

This retrospective study included 141 patients with duodenal SMTs. The therapeutic outcomes from ER and procedure-related complications were analyzed.

RESULTS

Of the 141 patients, 78.7% achieved complete resection and nine (6.4%) developed complications. The multivariate analysis suggested that location near the duodenal papilla (P = 0.010) and diameter exceeding 15 mm (P = 0.091) of duodenal SMTs were independent risk factors for complications in ER. Besides, submucosal fibrosis (P = 0.042), location near the duodenal papilla (P = 0.049), and irregular morphology (P = 0.067) were independent risk factors for incomplete resection.

CONCLUSIONS

ER can be recommended as an effective and minimally invasive treatment for duodenal SMTs.

Gasless endoscopic transaxillary thyroid surgery: CUSUM analysis of a single surgeon's experience from 105 preliminary procedures

BACKGROUND

We aimed to evaluate the feasibility and oncologic safety of gasless endoscopic transaxillary thyroidectomy (TAT) in patients with thyroid diseases. Improvements in surgical techniques were also reported, and the learning curves of gasless endoscopic TAT were further studied.

METHODS

An exact 1:1 matching analysis was performed to compare the technical safety and oncologic outcomes between TAT and conventional open surgery. A questionnaire was designed to evaluate the quality of life of enrolled patients. A cumulative summation analysis was designed for the quantitative estimation of the learning curves.

RESULTS

A total of 105 consecutive patients who successfully received endoscopic TAT were retrospectively enrolled in the current study. A standard three-step working space making procedure, an approach that does not free the superficial part of the sternal head of the sternocleidomastoid muscle (SCM, NFSSH) and a "point to line to surface" en bloc procedure utilized in lobectomy with ipsilateral central neck dissection (CND), were introduced in our surgical procedures. The mean operation time in the TAT group was significantly longer than that in the conventional open group (86.9 ± 31.3 vs 44.2 ± 8.3, p < 0.001). Significant differences in the complication rate were not found between the two groups. Discomfort in the anterior neck area and SCM was relieved over time in most cases (verbal response scores (VRSs) were gradually decreased over time). The learning curves for working space making, ipsilateral thyroidectomy and the total endoscopic TAT approach were 45 cases, 25 cases and 42 cases, respectively. The operation time in the proficient group was significantly shorter than that in the learning group (67.0 ± 8.4 vs 112.3 ± 35.7, p < 0.001). VRSs in the SCM were significantly lower in the proficient group (for 1 week: 1.25 ± 0.65 vs 2.40 ± 0.63, p < 0.001; for 1 month: 0.81 ± 0.69 vs 1.81 ± 0.40, p < 0.001).

CONCLUSIONS

Gasless endoscopic TAT was safe in a cohort of patients with thyroid diseases, with satisfactory surgical outcomes and cosmetic appearance. The learning curve for endoscopic TAT was approximately 42 cases. The proficiency of the endoscopic TAT approach depended primarily on the proficiency of working space making.

Survival comparison between endoscopic and surgical resection for non-ampullary duodenal neuroendocrine tumor (1-2 cm)

The treatment plan for non-ampullary duodenal neuroendocrine tumors (d-NETs) with diameters 1-2 cm remains controversial. We therefore aimed to compare the prognostic effects of endoscopic treatment and surgical resection on non-ampullary d-NETs with 1-2 cm diameters. A total of 373 eligible patients were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was performed to match patients 1:1 according to clinicopathological characteristics. Disease-specific survival (DSS) and overall survival (OS) were calculated. Before PSM, there was no significant difference in DSS or OS (all P > 0.05), but the T stage, N stage, and TNM stage were significantly different between the two surgical methods (all P < 0.05). After 1:1 PSM, the differences in clinicopathological characteristics were significantly reduced (all P > 0.05). Survival analysis showed that tumor grade was correlated with DSS and that age was correlated with OS (all P < 0.05); however, the surgical method and other clinicopathological characteristics were not correlated with prognosis (all P > 0.05). Subgroup survival analysis of patients with T2N0M0 disease and tumors invading the lamina propria or submucosa showed that the 5-year DSS and OS rates were not significantly different according to the surgical approach (all P > 0.05). The surgical approach has no significant effect on the prognosis of patients with non-ampullary d-NETs with 1-2 cm diameters, especially those with T2N0M0 disease. This suggests that endoscopic treatment may be a preferred option for these patients.

Endoscopic excision as a viable alternative to major resection for early duodenal cancers: A population-based cohort study

BACKGROUND

Duodenal cancer presents an elusive therapeutic challenge for clinicians to treat because of its highly malignant behavior and anatomical complexity. Endoscopic excision has been administered to treat early-stage cancers of upper gastrointestinal tract, especially esophagus and stomach cancer. There is currently a scarcity of data regarding the application and efficacy of endoscopic resection for early duodenal cancer due to its rarity. This study aimed at exploring the prevalence and efficacy of endoscopic excision in treatment for early duodenal cancer in comparison with major surgery.

METHODS

This cohort study retrospectively collected patients with primary Tis/T1-N0-M0 duodenal cancer in the Surveillance, Epidemiology, and End Results database from 2004 to 2017. Prevalence of endoscopic excision in duodenal cancer treatment, overall survival (OS) and disease-specific survival (DSS) of patients who received different tumor-resection procedures were estimated.

RESULTS

A total of 1354 patients with Tis/T1-stage duodenal cancer were identified. Most patients (69.4%) underwent tumor resection as initial treatments. Among them, 65.7% underwent endoscopic excision, while 34.3% underwent major surgery. The multivariable Cox analyses revealed that endoscopic excision was associated with a significantly favorable OS (HR: 0.70; 95% CI: 0.52-0.95, p = 0.02) and DSS (HR: 0.32; 95% CI: 0.17-0.60, p < 0.001), compared to major surgery, for Tis/T1-stage cancer patients. In addition to cancer-related deaths (p < 0.001), endoscopic resection manifested significantly lower cumulative mortality rate of post-operative infectious diseases (p = 0.03).

CONCLUSION

Endoscopic resection currently accounted for approximately two-thirds of all procedures to resect Tis/T1-stage duodenal tumor. Endoscopic resection represents a viable therapeutic option in the management of Tis/T1-stage duodenal cancer for its oncological superiorities to major surgery and its capacity to reduce operative traumas and morbidities.

Successful endoscopic removal of a giant duodenal bulb mass

A 53-year-old man presented to our hospital for resection of a duodenal mass because of the increasing diameter. Esophagogastroduodenoscopy revealed a giant oval mass in the back wall of duodenal bulb, which was protruded to the second part of duodenum(Figure 1). Endoscopic ultrasonography (EUS) revealed a submucosal mass with heterogeneous echogenicity and regular shape(Figure 2). Eventually, the patient received endoscopic submucosal dissection (ESD) after signing informed consent. The mass was resected completely and measured 6.0×4.2×3.0 cm [Figure 3]. Histopathological examination revealed a brunner's gland adenoma. There was no complication besides minor intraoperative bleeding. Both surgery and endoscopic resection (ER) are alternative treatments for duodenal adenoma, but the best way remains controversial. Due to the thin wall, narrow cavity and plentiful vascular network of the duodenal bulb, ER is challenging because of the technical difficulty and probability of perforation and bleeding [1]. Our previous study found that ER is an effective and safe way for treating duodenal adenoma on experienced hands, and ER possesses several advantages over surgical resection for selected patients [2，3]. In the present case, we removed the giant BGA by ESD, as far as we know, this is the largest yet removed by ER.

Minimally invasive management of large duodenal lipoma: endoscopic submucosal dissection

Objective

This study was performed to compare the clinical outcomes of large duodenal lipomas (DLs) of ≥2 cm between endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR).

Methods

This retrospective study included patients who underwent endoscopic resection of large DLs from June 2017 to March 2021 at our hospital. Clinicopathologic features, clinical outcomes, and follow-up endoscopy findings were retrospectively reviewed.

Results

Twenty-three patients (12 men) with a mean age of 57.4 years were included. The median tumor size was 28.4 ± 13.3 mm. ESD was performed in 19 patients, and EFTR was performed in 4. Complete resection was achieved in 21 patients. The operative time and postoperative hospital stay were significantly shorter in the ESD than EFTR group. Four patients in the EFTR group developed a fever; no other adverse events occurred. No patients required surgical intervention. During the average follow-up of 21.1 months, no residual tumor, recurrence, or metastasis was observed.

Conclusion

Both ESD and EFTR provide minimally invasive, localized treatment of selected DLs. ESD might have some advantages in resecting large DLs in terms of procedure time and hospitalization.