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Lemos Garcia J, Rosa I, Pereira da Silva J, Lage P, Claro I. Endoscopic Approach to Duodenal Adenomas in Familial Adenomatous Polyposis: A Retrospective Cohort. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2023; 30:430-436. [PMID: 38476155 PMCID: PMC10928868 DOI: 10.1159/000527209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 08/17/2022] [Indexed: 03/14/2024]
Abstract
Introduction Over 90% of the patients with familial adenomatous polyposis (FAP) will develop duodenal adenomas. Aim The aim of this study was to evaluate the effectiveness and safety of endoscopic excision of large duodenal adenomas in FAP patients. Methods All FAP patients from a familial risk clinic submitted to endoscopic therapy for duodenal adenomas ≥10 mm between January 2010 and February 2021 were included. Results From 151 FAP families, 22 patients (50 lesions) were included: 54.5% female; median follow-up 8.5 (IQR: 5.8-12.3) years after the first endoscopy. First therapeutic endoscopy occurred at a median age of 41.0 years (IQR: 33.0-58.2). Repeat therapeutic endoscopy was required in 54.5% of patients. Median size of the largest adenoma was 15 mm (IQR: 10-18 mm); resection was piecemeal in 63.1% and en bloc in the remaining. In 2 cases, the resection was incomplete (fibrosis due to previous resection and difficult positioning). Complications occurred in 6.3% of the resected lesions (4 patients): 2 immediate (bleeding, perforation); 4 in the first week (1 bleeding, 2 mild pancreatitis, 1 perforation requiring surgery; the latter two after ampullectomy). Histology revealed low-grade dysplasia adenomas in 90.1%; no adenocarcinomas were found. One patient with Spigelman stage IV disease not amenable to endoscopic control underwent elective duodenopancreatectomy (without duodenal cancer). Conclusion Endoscopic surveillance and treatment of duodenal adenomas in FAP patients was safe and effective in the prevention of duodenal cancer.
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Affiliation(s)
- Joana Lemos Garcia
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
| | - Isadora Rosa
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
- Familial Risk Clinic, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
| | - João Pereira da Silva
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
| | - Pedro Lage
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
- Familial Risk Clinic, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
| | - Isabel Claro
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
- Familial Risk Clinic, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
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WEO Newsletter. Dig Endosc 2023; 35:799-803. [PMID: 37678909 DOI: 10.1111/den.14647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
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Zhao Z, Jiao Y, Yang S, Zhou A, Zhao G, Guo S, Li P, Zhang S. Endoscopic diagnosis and treatment of superficial non-ampullary duodenal epithelial tumors: A review. J Transl Int Med 2023; 11:206-215. [PMID: 37662895 PMCID: PMC10474890 DOI: 10.2478/jtim-2023-0102] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Abstract
The surface of the small bowel mucosa is covered more than any other section of the digestive canal; however, the overall prevalence of small bowel tumors of the whole gastrointestinal tract is evidently low. Owing to the improvement in endoscopic techniques, the prevalence of small bowel tumors has increased across multiple countries, which is mainly due to an increase in duodenal tumors. Superficial non-ampullary duodenal epithelial tumors (SNADETs) are defined as tumors originating from the non-ampullary region in the duodenum that share similarities and discrepancies with their gastric and colorectal counterparts in the pathogenesis and clinicopathologic characteristics. To date, white light endoscopy (WLE) remains the cornerstone of endoscopic diagnosis for SNADETs. Besides, narrow-band imaging (NBI) techniques and magnifying endoscopy (ME) have been widely used in the clinic and endorsed by multiple guidelines and consensuses for SNADETs' evaluation. Confocal laser endomicroscopy (CLE), endocytoscopy (ECS), and artificial intelligence (AI) are also up-and-coming methods, showing an exceptional value in the diagnosis of SNADETs. Similar to the endoscopic treatment for colorectal polyps, the choices for SNADETs mainly include cold snare polypectomy (CSP), endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and laparoscopic endoscopic cooperative surgery (LECS). However, owing to the narrow lumen, rich vascularity, weak muscle layer, abundant Brunner's gland, and the hardship of endoscope control, the duodenum ranks as one of the most dangerous operating areas in the digestive tract. Therefore, endoscopists must anticipate the difficulties in endoscopic maneuverability, remain aware of the increased risk of complications, and then select the appropriate treatment according to the advantages and disadvantages of each method.
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Affiliation(s)
- Zheng Zhao
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
| | - Yue Jiao
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
| | - Shuyue Yang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
| | - Anni Zhou
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
| | - Guiping Zhao
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
| | - Shuilong Guo
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
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Kim GE, Siddiqui UD. Endoscopic Resection Techniques for Duodenal and Ampullary Adenomas. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2023; 8:330-335. [PMID: 37575136 PMCID: PMC10422085 DOI: 10.1016/j.vgie.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Background and Aims Duodenal polyps have a reported incidence of 0.3% to 4.6%. Sporadic, nonampullary duodenal adenomas (SNDAs) comprise less than 10% of all duodenal polyps, and ampullary adenomas are even less common. Nonetheless, the incidence continues to rise because of widespread endoscopy use. Duodenal polyps with villous features or those that are larger than 10 mm may raise concern for malignancy and require removal. We demonstrate endoscopic resection of SNDAs and ampullary adenomas using some of our preferred techniques. Methods The duodenum has several components that can make EMR of duodenal polyps technically challenging. Not only does the duodenum have a thin muscle layer, but it is also highly mobile and vascular, which may explain higher rates of perforation and bleeding of duodenal EMR reported in the literature compared with colon EMR. A standard adult gastroscope with a distal cap is commonly used for duodenal EMRs. Based on the location, however, side-viewing duodenoscopes or pediatric colonoscopes may be used. To prepare for EMR, a submucosal injection is performed for an adequate lift. The polyp is then resected via stiff monofilament snares and subsequently closed with hemostatic clips if feasible. The ampullectomy technique differs slightly from duodenal EMRs and carries the additional risk of pancreatitis. Submucosal injection in the ampulla may not lift well; thus, its utility is debatable. Biliary sphincterotomy should be performed, and based on endoscopist preference, the pancreatic duct (PD) guidewire can be left during resection to maintain access. After resection, a PD stent is placed to minimize pancreatitis risk. Results The video shows the aforementioned duodenal EMR techniques. Two clips of ampullectomy are also shown in the video. Conclusions A few common techniques used to perform duodenal EMR and ampullectomy are highlighted in the video. It is important to understand and manage adverse events associated with these procedures and to have established surveillance plans.
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Affiliation(s)
- Grace E Kim
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, University of Chicago, Chicago, Illinois
| | - Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics, University of Chicago, Chicago, Illinois
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Yang Y, Xu X, Wang M, Zhang Y, Zhou P, Yang S, Shu X, Xie C. Research trends on endoscopic mucosal resection: A bibliometric analysis from 1991 to 2021. Front Surg 2022; 9:994718. [PMCID: PMC9630576 DOI: 10.3389/fsurg.2022.994718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/30/2022] [Indexed: 11/07/2022] Open
Abstract
BackgroundIn recent years, the rapid development of digestive endoscopy technology has brought revolutionary changes to endoscopic therapy. A growing number of articles have been published annually. We aimed to explore global scientific outputs and hotspots of endoscopic mucosal resection (EMR) published by different countries, organizations, and authors.MethodsWe extracted relevant publications from the Web of Science Core Collection (WOSCC) on June 23, 2022. We examined the retrieved data by bibliometric analysis (e.g., cocited and cluster analysis, keyword co-occurrence) using the software CiteSpace and VOSviewer to analyze and predict the trends and hot spots in this field.ResultsA total of 2,695 papers were finally identified. The results showed that the number of articles fluctuated with the year and reached its peak in 2021. NATIONAL CANCER CENTER JAPAN was the most influential institution. MICHAEL J BOURKE and YUTAKA SAITO are two of the most prolific scholars. ENDOSCOPY and GASTROINTESTINAL ENDOSCOPY were the most productive journals. “Early gastric cancer” and “Barrett's esophagus” were the focus of EMR research. “Adverse events”, “cold snare polypectomy” and “outcomes” have become increasingly popular in recent years and could become hot spots in the future.ConclusionIn this study, we summarized the characteristics of the publications; identified the most influential countries, institutions, and journals; and identified the leading topics in the EMR field.
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Affiliation(s)
- Yihan Yang
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xuan Xu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Menghui Wang
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yang Zhang
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Pinglang Zhou
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Sifan Yang
- Faculty of Basic Medical Sciences, Xizang Minzu University, Xianyang, China
| | - Xu Shu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Correspondence: Chuan Xie Xu Shu
| | - Chuan Xie
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Correspondence: Chuan Xie Xu Shu
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Fu S, Gong J, Zhou M, Wang Y, Liu D, Tan Y. Risk Factors of Non-en Bloc Resection and Non-R0 Resection During Endoscopic Resection in the Treatment of Superficial Duodenal Epithelial Lesions. Front Oncol 2022; 12:881815. [PMID: 35669421 PMCID: PMC9163665 DOI: 10.3389/fonc.2022.881815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background Superficial duodenal epithelial lesions are precancerous lesions of duodenal carcinoma. Upper gastrointestinal endoscopy has been widely used in the screening and treatment of this disease. This article will collect the data of patients who underwent endoscopic resection of superficial duodenal epithelial lesions in our hospital from 2010 to 2021, aiming to describe the efficacy and safety of endoscopic resection, as well as to explore the risk factors of non-en bloc resection and non-R0 resection. Methods Patients who underwent endoscopic resection for superficial duodenal epithelial lesions in our hospital from January 2010 to September 2021 were selected. The curative effect was expressed by the en bloc resection rate and R0 resection rate. The safety was expressed by intra- or postoperative complications, such as bleeding and perforation. The potential risk factors of curative effect were analyzed by logistic regression. Results A total of 137 patients were included. The en bloc resection rate was 95.62% (131/137), R0 resection rate was 91.97% (126/137), the postoperative bleeding rate was 2.19% (3/137), and no postoperative perforation was found. The histology result of ectopic gastric mucosa was the risk factor of non-en bloc resection (OR: 8.86, 95% CI: 1.38-56.92); the lesion size ≥2 cm was the risk factor of non-R0 resection (OR: 12.55, 95% CI: 2.95-53.38). Conclusion Endoscopic resection is a safe and effective method for the treatment of superficial duodenal epithelial lesions. The histology result of ectopic gastric mucosa was the risk factor of non-en bloc resection and the lesion size ≥2 cm was the risk factor of non-R0 resection.
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Affiliation(s)
- Shifeng Fu
- Department of Gastroenterology, the Second Xiangya Hospital of Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Jian Gong
- Department of Gastroenterology, the Second Xiangya Hospital of Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Mei Zhou
- Department of Gastroenterology, the Second Xiangya Hospital of Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Yongjun Wang
- Department of Gastroenterology, the Second Xiangya Hospital of Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Deliang Liu
- Department of Gastroenterology, the Second Xiangya Hospital of Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Yuyong Tan
- Department of Gastroenterology, the Second Xiangya Hospital of Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
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Cho JH, Lim KY, Lee EJ, Lee SH. Clinical outcomes of endoscopic resection of superficial nonampullary duodenal epithelial tumors: A 10-year retrospective, single-center study. World J Gastrointest Surg 2022; 14:329-340. [PMID: 35664364 PMCID: PMC9131840 DOI: 10.4240/wjgs.v14.i4.329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/09/2022] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although premalignant duodenal lesions such as adenomas are uncommon, the incidences of these lesions have increased in recent times, and thus, the demand for minimally invasive treatments such as endoscopic resection (ER) has also increased. However, ER in the duodenum is more challenging than ER in other locations of the gastrointestinal tract.
AIM To evaluate the safety and efficacy of ER for superficial nonampullary duodenal epithelial tumors (SNADETs)
METHODS We performed a retrospective observational study on 56 consecutive patients (58 lesions) diagnosed with SNADETs that underwent ER from January 2011 to December 2020 at Yeungnam University Hospital. Patient demographics, lesion characteristics, and procedural and technical data were collected, and clinical outcomes, including procedure-related complications, completeness of resection, and recurrence were analyzed.
RESULTS Median patient age was 57 years [range, 26–77, 30 (53.6%) men]. Endoscopic mucosal resection (EMR) was performed on 57 lesions (98.3%) and snare polypectomy on one (1.7%). Lesions consisted of 52 adenomas with low-grade dysplasia (89.7%), 3 adenomas with high-grade dysplasia (5.2%), and 3 intramucosal adenocarcinomas (5.2%). There were 16 cases of intraprocedural bleeding (27.6%) and 1 case of delayed bleeding (1.7%), and all these 17 cases were successfully managed endoscopically. No perforation or procedure-related death occurred. Larger lesion size was associated with an increased risk of EMR-related bleeding (P = 0.033). During a median follow-up period of 23 mo (range 6–100 mo), no local recurrence occurred, despite the fact one-third of the patients (19 lesions, 32.8%) underwent piecemeal resection and 3 patients (3 lesions, 5.2%) that underwent en bloc resection had a pathologically determined positive lateral margin. No patient died from a primary duodenal neoplasm.
CONCLUSION The majority of SNADETs can be safely and curatively resected by EMR, and thus, based on consideration of the high incidence of fatal complications attributable to ESD, we conclude EMR, including piecemeal resection, should be considered the treatment of first choice for SNADETs.
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Affiliation(s)
- Joon Hyun Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu 42415, South Korea
| | - Ki Young Lim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu 42415, South Korea
| | - Eun Jung Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu 42415, South Korea
| | - Si Hyung Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu 42415, South Korea
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Kanzaki H, Matsueda K, Nakagawa M, Inaba T, Takatani M, Takenaka R, Yoshioka M, Imagawa A, Inoue M, Suzuki S, Tomoda J, Iwamuro M, Kawano S, Kawahara Y, Tanaka T, Okada H. Clinical characteristics and course of sporadic non-ampullary duodenal adenomas: A multicenter retrospective study. Medicine (Baltimore) 2021; 100:e27382. [PMID: 34596158 PMCID: PMC8483853 DOI: 10.1097/md.0000000000027382] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/11/2021] [Indexed: 01/05/2023] Open
Abstract
Sporadic non-ampullary duodenal adenoma (SNADA) is a rare disease, and therefore, its clinical characteristics have not been comprehensively investigated. Furthermore, owing to the high complication rates and severity of endoscopic resection, treatment strategies vary among facilities. In the present study, we aimed to clarify the clinical characteristics and course of SNADA.We extracted clinical and histological records of SNADA cases diagnosed in 11 hospitals between September 1999 and August 2014. The patients were divided into "no-resection" and "resection" groups based on the initial treatment approach. We investigated the long-term outcome of the "no-resection" group and treatment results of the "resection" group, with particular interest in endoscopic resection.Overall, 299 patients were diagnosed with SNADA. The median age at diagnosis was 67 years (range, 31-88 years), with approximately twice as many men as women. The median tumor size was 8.0 mm (2-60 mm). In total, 161 patients were initially selected for no-resection and 138 underwent resection. Age >70 years and the presence of either severe illness or poor performance status were significantly related to opting for no-resection. In the no-resection group, 101 patients underwent endoscopic follow-up for at least 1 year. During the observational period (2.5 ± 2.2 years), 27 lesions (27%) disappeared following cold forceps biopsy, and 13 lesions (14%) presented lateral growth. Four lesions (4%) changed to mucosal carcinoma, 3 were treated endoscopically, and 1 was surgically resected. Nineteen patients died; however, no one died of duodenal carcinoma. In the endoscopic resection group, en bloc resection was achieved in 78% of patients. However, the complication rate for perforation was 7%, and endoscopic submucosal dissection was associated with a 36% perforation rate.With the low incidence of cancer development and no disease specific death, the strategy of initially not performing resection could be considered especially for the older adults, poor-prognosis patients, or small lesions.
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Affiliation(s)
- Hiromitsu Kanzaki
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Okayama, Japan
| | - Kazuhiro Matsueda
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Masahiro Nakagawa
- Department of Endoscopy, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Hiroshima, Japan
| | - Tomoki Inaba
- Department of Gastroenterology, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Masahiro Takatani
- Department of Internal Medicine, Japanese Red Cross Society Himeji Hospital, Himeji, Hyogo, Japan
| | - Ryuta Takenaka
- Department of Internal Medicine, Tsuyama Chuo Hospital, Tsuyama, Okayama, Japan
| | - Masao Yoshioka
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Okayama, Okayama, Japan
| | - Atsushi Imagawa
- Department of Gastroenterology, Mitoyo General Hospital, Kanonji, Kagawa, Japan
| | - Masafumi Inoue
- Department of Gastroenterology, Japanese Red Cross Okayama Hospital, Okayama, Okayama, Japan
| | - Seiyuu Suzuki
- Department of Internal Medicine, Sumitomo Besshi Hospital, Niihama, Ehime, Japan
| | - Jun Tomoda
- Department of Internal Medicine, Akaiwa Medical Association Hospital, Akaiwa, Okayama, Japan
| | - Masaya Iwamuro
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Okayama, Japan
| | - Seiji Kawano
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Okayama, Japan
| | - Yoshiro Kawahara
- Department of Practical Gastrointestinal Endoscopy, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Takehiro Tanaka
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Okayama, Japan
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
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Yamamura M, Nagami Y, Sakai T, Maruyama H, Ominami M, Fukunaga S, Otani K, Hosomi S, Tanaka F, Taira K, Yamagami H, Tanigawa T, Watanabe T, Fujiwara Y. Safety of Endoscopic Mucosal Resection Using a Bipolar Snare for Superficial Nonampullary Duodenal Epithelial Tumors and the Predictive Factors of Piecemeal Resection. Digestion 2021; 102:682-690. [PMID: 33045711 DOI: 10.1159/000510601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/02/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Endoscopic mucosal resection for small superficial nonampullary duodenal epithelial tumors is a noninvasive treatment; however, perforations can occur. Bipolar snares can reduce the risk of perforation due to small tissue damage. Currently, only few studies have reported endoscopic mucosal resection for small superficial nonampullary duodenal epithelial tumors using a bipolar snare and the effect of preoperative findings. OBJECTIVE To investigate (1) resectability and adverse events of endoscopic mucosal resection using a bipolar snare for small superficial nonampullary duodenal epithelial tumors and (2) the predictions of piecemeal resection. METHODS Between 2007 and 2017, 89 patients with 107 lesions underwent endoscopic mucosal resection using a bipolar snare. Among them, 88 lesions of 77 patients were evaluated. The primary outcome was the incidence of en bloc resection and R0 resection and adverse events. Risk factors associated with piecemeal resection, including preoperative lesion findings, were also examined. RESULTS The incidence rates of en bloc and R0 resections were 85.2 and 48.9%, respectively. Neither intraoperative or delayed perforations nor procedure-related mortality was noted. The nonlifting sign after submucosal injection was associated with an increase in piecemeal resection (odds ratio: 20.3, 95% confidence interval: 2.53-162; p = 0.005). CONCLUSION Endoscopic resection for small superficial nonampullary duodenal epithelial tumors can cause perforation; however, endoscopic mucosal resection using a bipolar snare can be a safe treatment option as it does not cause perforations. The nonlifting sign after submucosal injection is a predictive factor for piecemeal resection.
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Affiliation(s)
- Masafumi Yamamura
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan,
| | - Taishi Sakai
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hirotsugu Maruyama
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shusei Fukunaga
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Koji Otani
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Hosomi
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Koichi Taira
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hirokazu Yamagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tetsuya Tanigawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshio Watanabe
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
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Brito HP, Torres IT, Turke KC, Parada AA, Waisberg J, Botelho RV. Comparison of endoscopic resection techniques for duodenal neuroendocrine tumors: systematic review. Endosc Int Open 2021; 9:E1214-E1221. [PMID: 34447867 PMCID: PMC8383086 DOI: 10.1055/a-1487-5594] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 03/29/2021] [Indexed: 12/12/2022] Open
Abstract
Background and study aims Regardless of size, duodenal neuroendocrine tumors (dNETs) should be considered potentially malignant. A complete resection without complications is essential to increase safety procedures. The aim of this review was to describe effectiveness and possible complications of endoscopic techniques resection for resectioning dNETs in patients with tumors ≤ 20 mm in diameter. Methods An electronic bibliographic search was conducted using MEDLINE (via PubMed), Embase, Cochrane Central, and Google Scholar virtual databases. The types of intervention were endoscopic mucosal resection alone (EMR) or with cap (EMR-C), with a ligation device (EMR-L), with previous elevation of the tumor (EMR-I) or with endoscopic submucosal dissection (ESD); argon plasm coagulation (APC), and polypectomy. The outcome measures adopted were presence of free margin associated with tumor resection, tumor recurrence, complications (bleeding and perforation), and length of the procedure. Results Ten publications were included with the result of 224 dNET resections. EMR alone and polypectomy resulted in the most significantly compromised margin. The most frequent complication was bleeding (n = 21), followed by perforation (n = 8). Recurrence occurred in 13 cases, the majority of those under EMR or EMR-I. Conclusions EMR-C or EMR-I should be preferred for resectioning of dNETs. Polypectomy should not be indicated for resection of dNETs due to the high occurrence of incomplete resections. EMR alone must be avoided due a higher frequency of compromised margin and recurrent surgery. ESD was associated with no recurrence, however, but an increased occurrence of bleeding and perforation.
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Affiliation(s)
| | | | | | | | - Jaques Waisberg
- Department of Surgery, ABC Medical School, Santo André, São Paulo, Brazil,Department of Surgery, Hospital do Servidor Público Estadual, São Paulo, São Paulo, Brazil
| | - Ricardo Vieira Botelho
- Department of Surgery, Hospital do Servidor Público Estadual, São Paulo, São Paulo, Brazil
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11
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Outcomes of thermal ablation of the defect margin after duodenal endoscopic mucosal resection (with videos). Gastrointest Endosc 2021; 93:1373-1380. [PMID: 33285144 DOI: 10.1016/j.gie.2020.11.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/20/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Laterally spreading lesions (LSLs) in the duodenum are conventionally treated by EMR. Recurrence is commonly encountered and can be difficult to treat safely due to the unique anatomic characteristics of the duodenum. Auxiliary techniques designed to prevent recurrence have not been described. METHODS We sought to evaluate the effectiveness of thermal ablation of the defect margin after EMR (EMR-T) in reducing recurrence at first surveillance endoscopy (SE1, scheduled at 6 months) in a single tertiary referral center. All duodenal LSLs ≥10 mm referred for EMR were eligible. After successful EMR, thermal ablation was performed using snare-tip soft coagulation around the entire circumference of the resection defect. The primary outcome was the frequency of recurrence at SE1. A previous, well-characterized, prospective cohort of duodenal LSLs ≥10 mm treated by conventional EMR was the comparator. RESULTS Over 43 months up to October 2019, 54 LSLs underwent EMR-T. One hundred twenty-five LSLs underwent conventional EMR in the comparator group. Patient and lesion characteristics were similar between the groups. Recurrence was significantly lower in the EMR-T group compared with the conventional EMR group (1 of 49 [2.3%] vs 19 of 108 [17.6%]; P = .01). No difference in technical success, EMR-related adverse outcomes, or referral to surgery were identified between the groups. CONCLUSIONS EMR-T significantly reduces the frequency of recurrence for duodenal LSLs. This technique is safe in the duodenum and has the potential to significantly improve the effectiveness of duodenal EMR. (Clinical trial registration number: NCT02306603.).
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12
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Vanbiervliet G, Moss A, Arvanitakis M, Arnelo U, Beyna T, Busch O, Deprez PH, Kunovsky L, Larghi A, Manes G, Napoleon B, Nalankilli K, Nayar M, Pérez-Cuadrado-Robles E, Seewald S, Strijker M, Barthet M, van Hooft JE. Endoscopic management of superficial nonampullary duodenal tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:522-534. [PMID: 33822331 DOI: 10.1055/a-1442-2395] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
1: ESGE recommends that all duodenal adenomas should be considered for endoscopic resection as progression to invasive carcinoma is highly likely.Strong recommendation, low quality evidence. 2: ESGE recommends performance of a colonoscopy, if that has not yet been done, in cases of duodenal adenoma.Strong recommendation, low quality evidence. 3: ESGE recommends the use of the cap-assisted method when the location of the minor and/or major papilla and their relationship to a duodenal adenoma is not clearly established during forward-viewing endoscopy.Strong recommendation, moderate quality evidence. 4: ESGE recommends the routine use of a side-viewing endoscope when a laterally spreading adenoma with extension to the minor and/or major papilla is suspected.Strong recommendation, low quality evidence. 5: ESGE suggests cold snare polypectomy for small (< 6 mm in size) nonmalignant duodenal adenomas.Weak recommendation, low quality evidence. 6: ESGE recommends endoscopic mucosal resection (EMR) as the first-line endoscopic resection technique for nonmalignant large nonampullary duodenal adenomas.Strong recommendation, moderate quality evidence. 7: ESGE recommends that endoscopic submucosal dissection (ESD) for duodenal adenomas is an effective resection technique only in expert hands.Strong recommendation, low quality evidence. 8: ESGE recommends using techniques that minimize adverse events such as immediate or delayed bleeding or perforation. These may include piecemeal resection, defect closure techniques, noncontact hemostasis, and other emerging techniques, and these should be considered on a case-by-case basis.Strong recommendation, low quality evidence. 9: ESGE recommends endoscopic surveillance 3 months after the index treatment. In cases of no recurrence, a further follow-up endoscopy should be done 1 year later. Thereafter, surveillance intervals should be adapted to the lesion site, en bloc resection status, and initial histological result. Strong recommendation, low quality evidence.
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Affiliation(s)
- Geoffroy Vanbiervliet
- Department of Digestive Endoscopy, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Alan Moss
- Department of Endoscopic Services, Western Health, Melbourne, Australia.,Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Urban Arnelo
- Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Torsten Beyna
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Nordrhein-Westfalen, Germany
| | - Olivier Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pierre H Deprez
- Gastroenterology and Hepatology Department, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Lumir Kunovsky
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianpiero Manes
- Aziende Socio Sanitaria Territoriale Rhodense, Gastroenterology, Garbagnate Milanese, Italy
| | - Bertrand Napoleon
- Service de Gastroentérologie, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Kumanan Nalankilli
- Department of Endoscopic Services, Western Health, Melbourne, Australia.,Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Manu Nayar
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Enrique Pérez-Cuadrado-Robles
- Department of Gastroenterology, Georges-Pompidou European Hospital, AP-HP Centre - Université de Paris, Paris, France
| | - Stefan Seewald
- Center of Gastroenterology Centre, Klinik Hirslanden, Zurich, Switzerland
| | - Marin Strijker
- Department of Gastroenterology, Hôpital Nord, Assistance publique des hôpitaux de Marseille, Marseille, France
| | - Marc Barthet
- Department of Gastroenterology, Hôpital Nord, Assistance publique des hôpitaux de Marseille, Marseille, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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13
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Yang HJ. Endoscopic Treatment for Superficial Nonampullary Duodenal Tumors. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 77:164-170. [PMID: 33896904 DOI: 10.4166/kjg.2021.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/03/2021] [Accepted: 03/03/2021] [Indexed: 12/13/2022]
Abstract
Superficial nonampullary duodenal epithelial tumors are considered rare but have been increasingly recognized in recent years. Accordingly, the importance of endoscopic treatment for the lesions are also increasing. An endoscopic resection can be considered for duodenal adenoma and mucosal cancer. The choice of resection method should be made based on the size of the lesion, endoscopic findings, pathologic diagnosis, and risk of procedure-related complication. For small adenomas <10 mm in size, endoscopic mucosal resection (EMR), cold snare polypectomy, and underwater EMR can be considered. An en bloc or piecemeal resection using EMR or underwater EMR can be selected for 10-20 mm sized adenomas. For lesions ≥20 mm in size or suspicious for mucosal cancer, an endoscopic submucosal dissection followed by closure of the mucosal defect conducted by an experienced endoscopist is appropriate.
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Affiliation(s)
- Hyo-Joon Yang
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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14
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Vanbiervliet G, Strijker M, Arvanitakis M, Aelvoet A, Arnelo U, Beyna T, Busch O, Deprez PH, Kunovsky L, Larghi A, Manes G, Moss A, Napoleon B, Nayar M, Pérez-Cuadrado-Robles E, Seewald S, Barthet M, van Hooft JE. Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:429-448. [PMID: 33728632 DOI: 10.1055/a-1397-3198] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
1: ESGE recommends against diagnostic/therapeutic papillectomy when adenoma is not proven.Strong recommendation, low quality evidence. 2: ESGE recommends endoscopic ultrasound and abdominal magnetic resonance cholangiopancreatography (MRCP) for staging of ampullary tumors.Strong recommendation, low quality evidence. 3: ESGE recommends endoscopic papillectomy in patients with ampullary adenoma without intraductal extension, because of good results regarding outcome (technical and clinical success, morbidity, and recurrence).Strong recommendation, moderate quality evidence. 4: ESGE recommends en bloc resection of ampullary adenomas up to 20-30 mm in diameter to achieve R0 resection, for optimizing the complete resection rate, providing optimal histopathology, and reduction of the recurrence rate after endoscopic papillectomy.Strong recommendation, low quality evidence. 5: ESGE suggests considering surgical treatment of ampullary adenomas when endoscopic resection is not feasible for technical reasons (e. g. diverticulum, size > 4 cm), and in the case of intraductal involvement (of > 20 mm). Surveillance thereafter is still mandatory.Weak recommendation, low quality evidence. 6: ESGE recommends direct snare resection without submucosal injection for endoscopic papillectomy.Strong recommendation, moderate quality evidence. 7: ESGE recommends prophylactic pancreatic duct stenting to reduce the risk of pancreatitis after endoscopic papillectomy.Strong recommendation, moderate quality evidence. 8: ESGE recommends long-term monitoring of patients after endoscopic papillectomy or surgical ampullectomy, based on duodenoscopy with biopsies of the scar and of any abnormal area, within the first 3 months, at 6 and 12 months, and thereafter yearly for at least 5 years.Strong recommendation, low quality evidence.
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Affiliation(s)
- Geoffroy Vanbiervliet
- Department of Digestive Endoscopy, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Marin Strijker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arthur Aelvoet
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Urban Arnelo
- Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Torsten Beyna
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Nordrhein-Westfalen, Germany
| | - Olivier Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pierre H Deprez
- Gastroenterology and Hepatology Department, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Lumir Kunovsky
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianpiero Manes
- Aziende Socio Sanitaria Territoriale Rhodense, Gastroenterology, Garbagnate Milanese, Italy
| | - Alan Moss
- Department of Endoscopic Services, Western Health, Melbourne, Australia.,Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Bertrand Napoleon
- Service de Gastroentérologie, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Manu Nayar
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Enrique Pérez-Cuadrado-Robles
- Department of Gastroenterology, Georges-Pompidou European Hospital, AP-HP Centre - Université de Paris, Paris, France
| | - Stefan Seewald
- Gastroenterology Center, Klinik Hirslanden, Zurich, Switzerland
| | - Marc Barthet
- Department of Gastroenterology, Hôpital Nord, Assistance publique des hôpitaux de Marseille, Marseille, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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15
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Roos VH, Bastiaansen BA, Kallenberg FGJ, Aelvoet AS, Bossuyt PMM, Fockens P, Dekker E. Endoscopic management of duodenal adenomas in patients with familial adenomatous polyposis. Gastrointest Endosc 2021; 93:457-466. [PMID: 32535190 DOI: 10.1016/j.gie.2020.05.065] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/30/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Almost all patients with familial adenomatous polyposis (FAP) develop duodenal adenomas, with a 4% to 18% risk of progression into duodenal cancer. Prophylactic endoscopic resection of duodenal adenomas may prevent cancer and is considered safer than surgical alternatives; however, data are limited. Therefore, the aim of this study was to assess safety and effectiveness of endoscopic duodenal interventions in patients with FAP. METHODS We performed a historical cohort study including patients with FAP who underwent an endoscopic duodenal intervention between 2002 and 2018. Safety was defined as adverse event rate per intervention and effectiveness as duodenal surgery-free and duodenal cancer-free survival. Change in Spigelman stage was assessed as a secondary outcome. RESULTS In 68 endoscopy sessions, 139 duodenal polypectomies were performed in 49 patients (20 men; median age, 43). Twenty-nine patients (14 men; median age, 49) underwent a papillectomy. After polypectomy, 9 (13%) bleedings and 1 (2%) perforation occurred, all managed endoscopically. Six (21%) bleedings (endoscopically managed), 4 (14%) cases of pancreatitis, and 1 (3%) perforation (conservatively treated) occurred after papillectomy. Duodenal surgery-free survival was 74% at 89 months after polypectomy and 71% at 71 months after papillectomy; no duodenal cancers were observed. After a median of 18 months (interquartile range, 10-40; range, 3-121) after polypectomy, Spigelman stages were significantly lower (P < .01). CONCLUSIONS In our FAP patients, prophylactic duodenal polypectomies were relatively safe. Papillectomies showed substantial adverse events, suggesting its benefits and risk should be carefully weighted. Both were effective, however, because surgical interventions were limited and none developed duodenal cancer.
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Affiliation(s)
- Victorine H Roos
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Barbara A Bastiaansen
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Frank G J Kallenberg
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Arthur S Aelvoet
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Patrick M M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam Gastroenterology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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16
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Hoibian S, Ratone JP, Gonzalez JM, Bories E, Pesenti C, Caillol F, Grimaud JC, Giovannini M, Barthet M. Endoscopic mucosal resection of sporadic duodenal nonampullary adenoma: outcomes of 130 patients with a long-term follow up in two tertiary French centers. Ann Gastroenterol 2021; 34:169-176. [PMID: 33654355 PMCID: PMC7903584 DOI: 10.20524/aog.2021.0581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/23/2020] [Indexed: 11/11/2022] Open
Abstract
Background The long-term outcomes and safety of endoscopic mucosal resection (EMR) of sporadic duodenal adenoma (SDA), and the management of adverse events need to be confirmed. Methods A bicentric retrospective study was performed including all patients who underwent EMR for SDAs from 2003-2016. The primary aim was to evaluate the efficiency of EMR for SDA. The secondary objectives were to assess safety, recurrence management, predictive factors for treatment success, and adverse events. Results One hundred thirty patients (134 procedures) were included (median age 65 years, 49.3% male). The mean SDA size was 20.7 (range 5-50) mm. Of the SDAs, 58.2% were category 3 of the Vienna classification, 35.8% were category 4, and 5.9% were category 5. The median follow up was 25.0 (range 2-120) months. Complete mucosal resection was achieved for 129/134 lesions (96.2%), with en bloc resection in 59/134 (44%). Recurrence occurred in 28.6% of cases (30/105 procedures). Recurrence was successfully treated by new endoscopic procedures in 72.2% (13/18) and by surgery in 27.8% (5/18). Delayed bleeding occurred in 13.4% of cases (18/134) and was successfully managed endoscopically. The perforation rate was 3.7% (5/134); perforations were managed without surgery in 60% (3/5 patients) of cases. Conclusions Endoscopic treatment of SDA appears to be effective and relatively safe in tertiary centers. All bleeding complications were endoscopically controlled, and perforation was rare. Recurrence was frequent but could be managed endoscopically. EMR is confirmed as a first-line treatment in cases of SDA, and surgery is useful only if repeated EMRs fail.
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Affiliation(s)
- Solène Hoibian
- Gastroenterology Unit, Hôpitaux Universitaires de Marseille Nord, Chemin des Bourrely (Solène Hoibian, Jean-Michel Gonzalez, Jean-Charles Grimaud, Marc Barthet).,Endoscopy Unit, Paoli-Calmettes Institute (Solène Hoibian, Jean-Philippe Ratone, Jean-Michel Gonzaleza Erwan Bories, Christian Pesenti, Fabrice Caillol, Marc Giovannini), Marseille, France
| | - Jean-Philippe Ratone
- Endoscopy Unit, Paoli-Calmettes Institute (Solène Hoibian, Jean-Philippe Ratone, Jean-Michel Gonzaleza Erwan Bories, Christian Pesenti, Fabrice Caillol, Marc Giovannini), Marseille, France
| | - Jean-Michel Gonzalez
- Gastroenterology Unit, Hôpitaux Universitaires de Marseille Nord, Chemin des Bourrely (Solène Hoibian, Jean-Michel Gonzalez, Jean-Charles Grimaud, Marc Barthet)
| | - Erwan Bories
- Endoscopy Unit, Paoli-Calmettes Institute (Solène Hoibian, Jean-Philippe Ratone, Jean-Michel Gonzaleza Erwan Bories, Christian Pesenti, Fabrice Caillol, Marc Giovannini), Marseille, France
| | - Christian Pesenti
- Endoscopy Unit, Paoli-Calmettes Institute (Solène Hoibian, Jean-Philippe Ratone, Jean-Michel Gonzaleza Erwan Bories, Christian Pesenti, Fabrice Caillol, Marc Giovannini), Marseille, France
| | - Fabrice Caillol
- Endoscopy Unit, Paoli-Calmettes Institute (Solène Hoibian, Jean-Philippe Ratone, Jean-Michel Gonzaleza Erwan Bories, Christian Pesenti, Fabrice Caillol, Marc Giovannini), Marseille, France
| | - Jean-Charles Grimaud
- Gastroenterology Unit, Hôpitaux Universitaires de Marseille Nord, Chemin des Bourrely (Solène Hoibian, Jean-Michel Gonzalez, Jean-Charles Grimaud, Marc Barthet)
| | - Marc Giovannini
- Endoscopy Unit, Paoli-Calmettes Institute (Solène Hoibian, Jean-Philippe Ratone, Jean-Michel Gonzaleza Erwan Bories, Christian Pesenti, Fabrice Caillol, Marc Giovannini), Marseille, France
| | - Marc Barthet
- Gastroenterology Unit, Hôpitaux Universitaires de Marseille Nord, Chemin des Bourrely (Solène Hoibian, Jean-Michel Gonzalez, Jean-Charles Grimaud, Marc Barthet)
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17
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Tanaka I, Hirasawa D, Saito H. A case of duodenal polyp at superior duodenal angle successfully treated by cap-assisted endoscopic mucosal resection. VideoGIE 2020; 5:681-683. [PMID: 33319142 PMCID: PMC7730507 DOI: 10.1016/j.vgie.2020.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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18
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Anliker O, Sieweke W, Töpfer A, Wülker I, Breidert M. [Full thickness resection of a pyloric adenoma in the proximal duodenum in a 67-year-old patient with attenuated polyposis coli]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2020; 58:767-772. [PMID: 32380553 DOI: 10.1055/a-1143-6640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Pyloric gland adenomas (PGAs) are very rare and underdiagnosed, mostly be founded in the stomach. Similar to colorectal adenomas they have a high risk of malignant transformation to adenocarcinoma up to 12-47 %. Endoscopic resections in the duodenum harbor a significant risk of complications. EMR is the current standard technique for treatment of duodenal non-ampullary adenomas. Complete resection rates are considerably high at about 90 %. Adverse events as bleeding was reported up to 25 %. ESD is not recommended for resection of duodenal lesions since the perforation rate may be as high as 35 %. Use of EFTR in the duodenum are limited to a single case study of 20 patients. CASE A 67 year old patient with attenuated polyposis coli presented for screening. Gastroscopy showed a 20 mm large, non-ampullary lesions in the proximal duodenum (pars I). The margins of the duodenal lesions were marked with a high-frequency (HF) probe. An integrated balloon dilatation (20 mm) of the upper esophageal sphincter and the pylorus was performed to facilitate advancing of the gastroduodenal FTRD® (Ovesco Endoscopy AG). After pulling the duodenal lesion into the cap with a grasper the FTRD clip was deployed and the lesion immediately resected with the preloaded snare. A single-shot antibiotic prophylaxis with 2 g ceftriaxone i. v. was administered during the intervention. Second-look endoscopy was scheduled 24 h after resection. The resectat showed histologically a gastric type adenoma of 18 mm in the proximal duodenum (immunohistochemistry positive for Mucin-1, Mucin-5, Mib 1). CONCLUSION Herein we present the first case of duodenal EFTR in a patient with attenuated FAP and a PGA. There are currently no specific guidelines for the removal and surveillance. ASGE recommends resection and surveillance endoscopy at 3-5 years interval.
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Affiliation(s)
- Oliver Anliker
- Abteilung Gastroenterologie/Hepatologie der Medizinischen Klinik, Stadtspital Waid, Zürich
| | - Wolfram Sieweke
- Abteilung Gastroenterologie/Hepatologie der Medizinischen Klinik, Stadtspital Waid, Zürich
| | - Antonia Töpfer
- Institut für Pathologie und Molekularpathologie, Universitätsspital Zürich, Zürich
| | | | - Matthias Breidert
- Abteilung Gastroenterologie/Hepatologie der Medizinischen Klinik, Stadtspital Waid, Zürich
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19
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Yang J, Gurudu SR, Koptiuch C, Agrawal D, Buxbaum JL, Abbas Fehmi SM, Fishman DS, Khashab MA, Jamil LH, Jue TL, Law JK, Lee JK, Naveed M, Qumseya BJ, Sawhney MS, Thosani N, Wani SB, Samadder NJ. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in familial adenomatous polyposis syndromes. Gastrointest Endosc 2020; 91:963-982.e2. [PMID: 32169282 DOI: 10.1016/j.gie.2020.01.028] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/18/2020] [Indexed: 02/08/2023]
Abstract
Familial adenomatous polyposis (FAP) syndrome is a complex entity, which includes FAP, attenuated FAP, and MUTYH-associated polyposis. These patients are at significant risk for colorectal cancer and carry additional risks for extracolonic malignancies. In this guideline, we reviewed the most recent literature to formulate recommendations on the role of endoscopy in this patient population. Relevant clinical questions were how to identify high-risk individuals warranting genetic testing, when to start screening examinations, what are appropriate surveillance intervals, how to identify endoscopically high-risk features, and what is the role of chemoprevention. A systematic literature search from 2005 to 2018 was performed, in addition to the inclusion of seminal historical studies. Most studies were from worldwide registries, which have compiled years of data regarding the natural history and cancer risks in this cohort. Given that most studies were retrospective, recommendations were based on epidemiologic data and expert opinion. Management of colorectal polyps in FAP has not changed much in recent years, as colectomy in FAP is the standard of care. What is new, however, is the developing body of literature on the role of endoscopy in managing upper GI and small-bowel polyposis, as patients are living longer and improved endoscopic technologies have emerged.
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Affiliation(s)
- Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Suryakanth R Gurudu
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Cathryn Koptiuch
- Department of Population Sciences, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Deepak Agrawal
- Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Syed M Abbas Fehmi
- Department of Gastroenterology, University of California, San Diego, California, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Laith H Jamil
- Section of Gastroenterology and Hepatology, Beaumont Hospital-Royal Oak, Royal Oak, Michigan, USA
| | - Terry L Jue
- Department of Gastroenterology, The Permanente Medical Group, San Francisco, California, USA
| | - Joanna K Law
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mariam Naveed
- Advent Health Medical Group, Gastroenterology/Hepatology, Advent Health Hospital Altamonte Springs, Altamonte Springs, Florida, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, University of Florida, Gainsville, Florida, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nirav Thosani
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Sachin B Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - N Jewel Samadder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
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Andrisani G, Di Matteo FM. Endoscopic full-thickness resection of duodenal lesions (with video). Surg Endosc 2019; 34:1876-1881. [PMID: 31768725 DOI: 10.1007/s00464-019-07269-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 11/12/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM The endoscopic treatment of non-lifting or submucosal duodenal lesions is associated with a high risk of incomplete resection and adverse events. Clip-assisted endoscopic full-thickness resection (EFTR) is a new approach for en bloc removal of neoplastic lesions in the GI tract. The aim of this study was to investigate its efficacy and safety in the duodenum. MATERIALS AND METHODS We retrospectively collected all consecutive patients with duodenal lesions who underwent EFTR with OTSC (Ovesco Endoscopy, Tübingen, Germany) or the new full-thickness resection device (FTRD; Ovesco Endoscopy, Tübingen, Germany). Complete resection rate was defined as histologically-verified R0 resection. Main endoscopic and clinical outcomes (technical success, rate of EFTR, adverse events) were systematically assessed at 3 and 6 months. RESULTS Between May 2017 and January 2019, 10 patients with duodenal lesions underwent EFTR (5 non-lifting adenomas, 2 adenomas recurrence/relapse and 3 subepithelial tumours). Technical success was overall achieved in 8/10 cases (80%). The two FTRD failed cases were completed with snare resection. The complete full-thickness resection rate was achieved in 8/10 (80%), while in two cases it was limited to mucosal or submucosal layer. R0 resection rate was achieved in 8/10 (80%) patients. The mean procedure time was 75 min (range 53-120 min). There were no major adverse events. At 3 and 6-month follow-up, no recurrence was observed. CONCLUSIONS Clip-assisted EFTR is a feasible and effective technique for en bloc resection of "difficult" superficial neoplasia and submucosal lesions in the duodenum, representing another technique that must be part of the endoscopist's armamentarium.
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Affiliation(s)
- Gianluca Andrisani
- Digestive Endoscopy Unit, Campus Bio-Medico, University of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy.
| | - Francesco Maria Di Matteo
- Digestive Endoscopy Unit, Campus Bio-Medico, University of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
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Pérez-Cuadrado-Robles E, Quénéhervé L, Margos W, Shaza L, Ivekovic H, Moreels TG, Yeung R, Piessevaux H, Coron E, Jouret-Mourin A, Deprez PH. Comparative analysis of ESD versus EMR in a large European series of non-ampullary superficial duodenal tumors. Endosc Int Open 2018; 6:E1008-E1014. [PMID: 30083592 PMCID: PMC6075950 DOI: 10.1055/a-0577-7546] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND STUDY AIMS The choice of endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) in non-ampullary superficial duodenal tumors (NASDTs) is challenging and the benefits of ESD remain unclear. The aim was to comparatively analyze the feasibility, outcomes and safety of these techniques in these lesions. PATIENTS AND METHODS This is an observational and retrospective study. All consecutive patients presenting with NASDTs who underwent EMR or ESD between 2005 and 2017 were included. The following main outcomes were comparatively evaluated: en-bloc and complete (R0) resection rates, and local recurrence. Secondary outcomes were perforation and delayed bleeding. RESULTS One hundred sixty-six tumors in 150 patients (age: 66 years, range: 31 - 83, 42.7 % males) were resected by ESD (n = 37) or EMR (n = 129) and included. The median procedure time (81 vs. 50 min, P = 0.007) and tumor size (25 vs. 20 mm, P = 0.01) were higher in the ESD group. The global malignancy rate was 50.3 %. There were no differences in en-bloc resection (29.7 % vs. 44.2 %, P = 0.115), complete resection (19.4 % vs. 35.5 %, P = 0.069), and local recurrence (14.7 % vs. 16.7 %, P = 0.788) rates. Tumor size was associated with recurrence (28 vs. 20 mm, P = 0.008), with a median follow-up of 6.5 months. Focal recurrence (n = 22, 13.3 %) was treated endoscopically in 86.4 %. En-bloc resection in the ESD group was comparable in large ( ≥ 20 mm) and small lesions (27.6 % vs. 37.5 %, P = 0.587), while this outcome decreased significantly in large lesions resected by EMR (17.4 % vs. 75 %, P < 0.001). Nine perforations were confirmed in 6 lesions (16.2 %) resected by ESD and 3 (2.3 %) by EMR ( P = 0.001). Endoscopic therapy was successful in all but 1 patient (88.9 %) presenting with a delayed perforation. CONCLUSIONS ESD may be an alternative to EMR and surgery in selected NASDTs, such as large duodenal tumors where EMR achieves low en-bloc resection rates and the local recurrence may be higher. However, this technique may have a higher risk of perforations.
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Affiliation(s)
- Enrique Pérez-Cuadrado-Robles
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Lucille Quénéhervé
- Institut des Maladies de l’Appareil digestif, University Hospital of Nantes, France
| | - Walter Margos
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Leila Shaza
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Hrvoje Ivekovic
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Tom G. Moreels
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Ralph Yeung
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Hubert Piessevaux
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Emmanuel Coron
- Institut des Maladies de l’Appareil digestif, University Hospital of Nantes, France
| | - Anne Jouret-Mourin
- Department of Pathology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Pierre H. Deprez
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium,Corresponding author Pierre H. Deprez Department of Hepato-GastroenterologyCliniques universitaires Saint-LucUniversité Catholique de LouvainBrusselsBelgium
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Bauder M, Schmidt A, Caca K. Endoscopic full-thickness resection of duodenal lesions-a retrospective analysis of 20 FTRD cases. United European Gastroenterol J 2018; 6:1015-1021. [PMID: 30228889 PMCID: PMC6137579 DOI: 10.1177/2050640618773517] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 04/05/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Endoscopic resections in the duodenum harbor a significant risk of complications. The full-thickness resection device (FTRD) has shown favorable results concerning efficacy and safety in the resection of colorectal lesions. Data of its use in the duodenum are limited to a single, small case series (n = 4). METHODS Data of all consecutive patients scheduled for endoscopic full-thickness resection (EFTR) of duodenal lesions by FTRD in our institution were collected and analyzed retrospectively. Primary endpoint was technical success. RESULTS Between March 2014 and June 2017 EFTR of a duodenal lesion was planned in a total of 20 patients. Overall technical success was 17/20 (85.0%). Indication for EFTR was: adenomas (n = 13, seven treatment naïve, six pretreated), subepithelial tumors (n = 5) and T1 adenocarcinoma (n = 1). The FTRD could be advanced to the lesion in 19/20 cases (95.0%). R0-resection rate was 12/19 (63.2%). During follow-up after 3 and 12 months there were two recurrent adenomas that were successfully re-resected by FTRD. Minor bleedings occurred at the first postinterventional day in 3/19 (15.8%). There were no major bleedings and perforations. CONCLUSION This study confirmed the feasibility of duodenal EFTR and indicates good efficacy and safety. Larger studies are needed to further investigate this novel technique.
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Affiliation(s)
- Markus Bauder
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Arthur Schmidt
- Department of Gastroenterology, Medical Center, University of Freiburg, Freiburg im Breisgau, Baden-Württemberg, Germany
| | - Karel Caca
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
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23
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Valli PV, Mertens JC, Sonnenberg A, Bauerfeind P. Nonampullary Duodenal Adenomas Rarely Recur after Complete Endoscopic Resection: A Swiss Experience Including a Literature Review. Digestion 2018; 96:149-157. [PMID: 28854423 DOI: 10.1159/000479625] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/17/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Duodenal polyps and especially duodenal adenomas are a rare and mostly coincidental finding in patients undergoing upper gastrointestinal endoscopy. Due to their malignant potential, duodenal adenomas should be removed upon diagnosis. So far, the limited available data on the performance of endoscopic polypectomy show conflicting results with regard to adverse events and the adenoma recurrence rate. PATIENTS AND METHODS After summarizing the currently available data, we retrospectively analyzed all patients undergoing endoscopic resection of nonampullary duodenal adenomas (NAD) at our institution between 2006 and 2016. RESULTS A total of 78 patients underwent endoscopic polypectomy for NAD adenoma. End-of-treatment success with complete resection requiring a mean of 1.2 interventions was achieved in 91% (n = 71). Procedural hemorrhage occurred in 12.8% (n = 10), whereas delayed bleeding was noted in 9% (n = 7). Duodenal perforation was registered and successfully treated in 2 cases (2.6%). No adenoma recurrence was noted following primary complete adenoma resection after a mean follow-up time of 33 months. Acute post-polypectomy bleeding was statistically significantly associated with large polyp size (p = 0.003) and lack of endoscopic prophylaxis (p = 0.0008). Delayed post-polypectomy bleeding showed a trend in the occurrence of large polyps (p = 0.064), and was statistically significantly associated with familial cancer syndrome (p = 0.019) and advanced histopathology (p = 0.013). CONCLUSION Our data suggest that endoscopic polypectomy of NAD is well feasible with high success rates. Procedural and delayed hemorrhage seems to be the primary issue rather than adenoma recurrence. We therefore advocate referral of patients with large NAD to experienced centers for endoscopic resection.
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Affiliation(s)
- Piero V Valli
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
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24
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Tomizawa Y, Ginsberg GG. Clinical outcome of EMR of sporadic, nonampullary, duodenal adenomas: a 10-year retrospective. Gastrointest Endosc 2018; 87:1270-1278. [PMID: 29317270 DOI: 10.1016/j.gie.2017.12.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 12/03/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Sporadic non-ampullary duodenal adenomas (SNADAs), although uncommon, pose clinical challenges. Because SNADAs have malignant potential, endoscopic or surgical resection is generally recommended. EMR is increasingly used for resection of SNADAs, but large-scale data on natural history after EMR are scarce. In this study, we aimed to evaluate the clinical outcome of EMR for SNADAs and the natural history after EMR from a large, single-operator experience with dedicated follow-up. METHODS We performed a retrospective review of patients with SNADAs who were referred for endoscopic therapy from May 2007 to May 2016. Patient demographics, lesion characteristics, and procedural technical data were collected. The outcomes studied were complete endoscopic resection, major adverse events, and recurrence. RESULTS A total of 162 patients were referred for endoscopic therapy, and 142 (88%) (median age 67 years, interquartile range [IQR] 57-73 years, 42% male) underwent a total of 166 EMRs with the use of a submucosal injection and thermal snare resection technique. In per-patient analysis, the median size of SNADAs was 20 mm (IQR 15-30) in diameter. Complete mucosal resection was achieved in 130 of 142 patients (92%). Local or residual recurrences were observed in 23% of patients (median time until recurrence 277 days [IQR 196-591]) and were treated endoscopically. No metachronous recurrences were found within a median follow-up of 363 days. In per-procedure analysis, en bloc resection was achieved in 88 (53%). EMR-related bleeding occurred in 18 (11%) EMRs, and all cases were successfully managed with supportive and/or endoscopic measures. No perforations occurred. Increasing size of adenomas was associated with recurrence (P < .001). No association with recurrence was noted with endoscopic or histologic features. Increasing size of resected specimens (P < .001) was associated with an increased risk of bleeding. CONCLUSION EMR of most SNADAs can be performed safely and effectively. Increasing size of adenomas was associated with recurrence and bleeding after EMR. No association with recurrence was noted with endoscopic or histologic features. Focal recurrence can be managed with additional endoscopic therapy. Metachronous lesions do not occur. The findings inform directed management and surveillance.
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Affiliation(s)
- Yutaka Tomizawa
- Division of Gastroenterology, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Gregory G Ginsberg
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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25
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Valerii G, Tringali A, Landi R, Boškoski I, Familiari P, Bizzotto A, Perri V, Petruzziello L, Costamagna G. Endoscopic mucosal resection of non-ampullary sporadic duodenal adenomas: a retrospective analysis with long-term follow-up. Scand J Gastroenterol 2018; 53:490-494. [PMID: 29458293 DOI: 10.1080/00365521.2018.1438508] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE We investigate the efficiency of endoscopic mucosal resection (EMR) of non-ampullary sporadic duodenal adenomas (NASDA) in a retrospective analysis with long-term follow-up. METHODS Consecutive patients undergoing EMR of NASDA between May 2002 and December 2016 were retrospectively identified from an electronic database. Endoscopic follow-up was scheduled after 3, 6 and 12 months for the first year, then yearly for up to five years. RESULTS EMR of 75 NASDA was performed in 68 patients (56% en-bloc, 44% piecemeal). Retroperitoneal perforations occurred in 3/68 (4.4%) patients, were treated by surgical (n = 2) or percutaneous (n = 1) drainage; delayed bleeding was reported in 13/75 (17.3%) resections and was successfully managed by endoscopy (n = 12) or radiologic embolization (n = 1). There was no procedure-related mortality. Follow-up was available in 61/68 patients (89.7%) after a median time of 59 months from resection. Residual and recurrent adenoma were diagnosed in 9 (14.5%) and 6 (10.9%) cases, respectively; all but one were successfully retreated endoscopically. CONCLUSIONS EMR for NASDA is effective with a favorable long-term outcome. Local recurrences can be retreated endoscopically. A recall system, patient's compliance to endoscopic follow-up are mandatory to detect recurrences and their prompt treatment.
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Affiliation(s)
- Giorgio Valerii
- a Digestive Endoscopy Unit , Fondazione Policlinico Universitario "A. Gemelli" - Catholic University , Rome , Italy
| | - Andrea Tringali
- a Digestive Endoscopy Unit , Fondazione Policlinico Universitario "A. Gemelli" - Catholic University , Rome , Italy
| | - Rosario Landi
- a Digestive Endoscopy Unit , Fondazione Policlinico Universitario "A. Gemelli" - Catholic University , Rome , Italy
| | - Ivo Boškoski
- a Digestive Endoscopy Unit , Fondazione Policlinico Universitario "A. Gemelli" - Catholic University , Rome , Italy
| | - Pietro Familiari
- a Digestive Endoscopy Unit , Fondazione Policlinico Universitario "A. Gemelli" - Catholic University , Rome , Italy
| | | | - Vincenzo Perri
- a Digestive Endoscopy Unit , Fondazione Policlinico Universitario "A. Gemelli" - Catholic University , Rome , Italy
| | - Lucio Petruzziello
- a Digestive Endoscopy Unit , Fondazione Policlinico Universitario "A. Gemelli" - Catholic University , Rome , Italy
| | - Guido Costamagna
- a Digestive Endoscopy Unit , Fondazione Policlinico Universitario "A. Gemelli" - Catholic University , Rome , Italy.,c Digestive Endoscopy, IHU-USIAS , University of Strasbourg , Strasbourg , France
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26
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Jamil LH, Kashani A, Peter N, Lo SK. Safety and efficacy of cap-assisted EMR for sporadic nonampullary duodenal adenomas. Gastrointest Endosc 2017; 86:666-672. [PMID: 28257791 DOI: 10.1016/j.gie.2017.02.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 02/16/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Eradication of sporadic nonampullary duodenal adenomas (SNADAs) is essential because of their high rate of malignant transformation. EMR techniques are the alternative to the traditional surgical treatments of SNADAs. There are very limited data on the safety and efficacy of cap-assisted EMR (C-EMR) in the treatment of SNADA. METHODS The medical records of patients who underwent C-EMR for SNADAs between July 2002 and April 2013 were retrospectively reviewed. Eradication was defined as no residual adenoma on follow-up or en bloc resection on pathology. Recurrence was defined as finding adenoma after a negative follow-up. RESULTS Fifty-nine C-EMR sessions were performed on 49 SNADAs (flat, 46; sessile, 3); 39 polyps were treated in piecemeal fashion and 10 polyps with en bloc resection. The polyp histology was tubular adenoma (63.3%) and tubulovillous adenoma (36.7%), with 16.3% of lesions showing high-grade dysplasia. Initial eradication rate was 90.5%; residual adenomas were successfully treated with repeat C-EMR/snare, resulting in 100% ultimate eradication rate without any recurrences (median follow-up of 17 months). The overall adverse events rate was 16.9%: intraprocedural bleeding (10.2%), delayed GI bleeding (5.1%), and perforation (1.7%). Among large polyps (≥15 mm), the initial and ultimate eradication rates were 87.9% and 100%, respectively, and the adverse event rate was 17%. Initial eradication rate for small polyps was higher than in large polyps (100% vs 87.9%, respectively; P = .02). CONCLUSION C-EMR is a highly efficient and safe method for the treatment of SNADAs. We recommend that endoscopists should learn C-EMR on esophageal, gastric, rectal, or left-sided colonic lesions before attempting C-EMR in the duodenum.
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Affiliation(s)
- Laith H Jamil
- Department of Gastroenterology, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Amir Kashani
- Department of Gastroenterology, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Neiveen Peter
- Department of Medicine, Glendale Adventist Medical Center, Glendale, California, USA
| | - Simon K Lo
- Department of Gastroenterology, Cedars Sinai Medical Center, Los Angeles, California, USA
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Kinoshita S, Nishizawa T, Ochiai Y, Uraoka T, Akimoto T, Fujimoto A, Maehata T, Goto O, Kanai T, Yahagi N. Accuracy of biopsy for the preoperative diagnosis of superficial nonampullary duodenal adenocarcinoma. Gastrointest Endosc 2017; 86:329-332. [PMID: 28003118 DOI: 10.1016/j.gie.2016.12.007] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/04/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic biopsy sampling for the diagnosis of duodenal adenocarcinoma is not perfect. We investigated the accuracy of biopsy specimen diagnoses of superficial nonampullary duodenal epithelial tumors (NADETs). METHODS Clinicopathologic data were retrospectively reviewed for 95 superficial NADETs from 95 patients who underwent endoscopic resection. Preoperative diagnoses based on biopsy specimens were compared with histologic diagnoses of resected specimens. RESULTS Among the 21 lesions with biopsy specimen diagnoses of carcinoma, 12 (57.1%) were histologically diagnosed as adenomas after resection. Among the 74 lesions with biopsy specimen diagnoses of adenoma, 15 (20.3%) were histologically diagnosed as carcinomas after resection. The duodenal biopsy specimen predicted final histologic diagnoses of carcinoma with a sensitivity of 37.5% (95% CI, 18.8-59.4), specificity of 83.1% (95% CI, 72.3-91.0), accuracy of 71.6% (95% CI, 61.4-80.4), positive predictive value of 42.9% (95% CI, 21.8-66.0), and negative predictive value of 79.7% (95% CI, 68.8-88.2). Among 61 cases considered suitable for EMR, treatment modality was converted from EMR to endoscopic submucosal dissection because of the nonlifting sign in 15 cases (24.6%). CONCLUSIONS The accuracy of duodenal biopsy sampling was relatively low. Duodenal biopsy sampling may induce unexpected fibrosis. New endoscopic modalities that can improve preoperative diagnosis yield of NADETs are eagerly awaited.
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Affiliation(s)
- Satoshi Kinoshita
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Toshihiro Nishizawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yasutoshi Ochiai
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Toshio Uraoka
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Teppei Akimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Ai Fujimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Tadateru Maehata
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
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Ma MX, Bourke MJ. Management of duodenal polyps. Best Pract Res Clin Gastroenterol 2017; 31:389-399. [PMID: 28842048 DOI: 10.1016/j.bpg.2017.04.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 04/28/2017] [Indexed: 01/31/2023]
Abstract
Duodenal adenomas are the most common type of polyp arising from the duodenum. These adenomas can occur within and outside of genetic syndromes, and are broadly classified as non-ampullary or ampullary depending on their location. All adenomas have malignant potential and are therefore appropriately treated by endoscopic resection. However, the unique anatomical properties of the duodenum, namely its relatively thin and vascular walls, narrow luminal diameter and relationship to the ampulla and its associated pancreatic and biliary drainage, pose an increased degree of complexity for any endoscopic interventions in this area. This review will discuss the epidemiology of duodenal adenomas, their endoscopic detection and diagnosis, and techniques for safe and effective endoscopic resection of ampullary and non-ampullary lesions.
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Affiliation(s)
- Michael X Ma
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia.
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29
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Duodenal adenomas in sporadic and familial adenomatous polyposis patients: Birds of a feather? Gastrointest Endosc 2017; 85:813-815. [PMID: 28317691 DOI: 10.1016/j.gie.2016.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 12/21/2016] [Indexed: 12/11/2022]
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