Usefulness and safety of endoscopic treatment for nonampullary duodenal adenoma and adenocarcinoma

Usefulness of the S-O clip for duodenal endoscopic submucosal dissection: a propensity score-matched study

BACKGROUND/AIMS

Endoscopic submucosal dissection (ESD) for superficial non-ampullary duodenal tumors (SNADETs) is associated with a high rate of en bloc resection. However, the technique for ESD remains challenging. Recent studies have demonstrated the effectiveness of S-O clips in colonic and gastric ESD. We evaluated the efficacy and safety of duodenal ESD using an S-O clip for SNADETs.

METHODS

Consecutive patients who underwent ESD for SNADETs between January 2011 and December 2021 were retrospectively enrolled. Propensity score matching analysis was used to compare patients who underwent duodenal ESD with the S-O clip (S-O group) and those who underwent conventional ESD (control group). Intraoperative perforation rate was the primary outcome, while procedure time and R0 resection rate were the secondary outcomes.

RESULTS

After propensity score matching, 16 pairs were created: 43 and 17 in the S-O and control groups, respectively. The intraoperative perforation rate in the S-O group was significantly lower than that in the control group (p=0.033). A significant difference was observed in the procedure time between the S-O and control groups (39±9 vs. 82±30 minutes, respectively; p=0.003).

CONCLUSION

The S-O clip reduced the intraoperative perforation rate and procedure time, which may be useful and effective in duodenal ESD.

Clinical outcomes of endoscopic resection of superficial nonampullary duodenal epithelial tumors: A 10-year retrospective, single-center study

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.

Long-term outcomes of endoscopic resection for non-ampullary duodenal epithelial tumors: A single-center experience

BACKGROUND/AIMS

The malignant potential of non-ampullary duodenal epithelial tumors (NADETs) is lower compared to that of other gastrointestinal epithelial tumors, but it should not be overlooked. Recently, endoscopic resection (ER) has been proposed as an alternative treatment option for NADETs. Therefore, we aimed to analyze the clinical outcomes of ER of NADETs and determine the factors associated with an incomplete resection.

MATERIALS AND METHODS

We conducted a retrospective observational study of 54 patients (56 lesions) with NADETs, who underwent ER in the period between October 2006 and March 2016, and analyzed the therapeutic outcomes and procedure-related adverse events.

RESULTS

Endoscopic mucosal resection (EMR) was performed on 41 lesions, and endoscopic submucosal dissection (ESD) was performed on 15 lesions. The en bloc and complete resection rates were 82% (46/56) and 54% (30/56), respectively. Multivariate logistic regression analyses determined that the resection method (EMR: odds ratio 4.356, 95% confidence interval 1.021-18.585, p=0.047) was independently associated with incomplete resection. The procedure-related bleeding and perforation rates were 4% and 5%, respectively. Recurrence of tumor occurred in one of 44 patients during the median follow-up period of 25 months (range: 6-89 months).

CONCLUSION

ER is an effective, safe, and feasible treatment option for NADETs. However, the incomplete resection rate increases when EMR is performed. Nevertheless, given the longer procedure time and the technical difficulty associated with ESD, and the excellent long-term outcomes associated with EMR, EMR of NADETs is appropriate, especially in patients with dysplastic lesions.

Endoscopic resection in combination with ligation for the treatment of duodenal subepithelial lesions: a single-center experience

Duodenal subepithelial lesions (SELs) are increasingly detected during an endoscopic examination. However, no feasible and safe methods are available for removing duodenal SELs. In the present study, we aimed to assess the feasibility and safety of endoscopic resection in combination with ligation (ER-L) in removing the duodenal SELs. A total of 101 patients with duodenal SELs received ER-L from February 2010 to February 2020. The primary outcomes were complete resection, en bloc resection, and R0 resection. The secondary outcomes included procedure duration, bleeding, perforation, and residual lesions. A total of 101 patients with 101 duodenal SELs (ranged from 8.4 mm to 20.2 mm in size) were included in this study. Most of the SELs (95.1%) originated from the submucosal layer and were successfully removed using ER-L. The rates of complete resection, en bloc resection, and R0 resection were 100%, 96.0%, and 88.1%, respectively. The median procedure duration was 8 min. There was no severe complication, except for four patients who developed post-procedure bleeding (4.0%) and recovered after conservative treatment. Furthermore, no residual lesions were detected during the follow-up period (median of 36 months). Indeed, logistic regression analysis showed that the size of duodenal SELs was an independent factor for R0 resection during the ER-L procedure. Conclusively, ER-L was feasible and safe to remove the duodenal SELs that originated from the submucosal layer and were less than 20 mm. However, the feasibility and safety of the ER-L should be further confirmed when removing the duodenal SELs that originated from the muscularis propria (MP) layer and were larger than 20 mm in diameter.

Case series of non-ampullary duodenal adenomas

Duodenal adenomas are benign tumours of the duodenum which carry a malignant potential. They are found either sporadically or associated with familial syndromes. Majority of these cases are treated endoscopically but surgical resection is a better alternate to endoscopy in select cases. Endoscopic treatment is associated with higher chances of local recurrence and require frequent check endoscopies in the follow up period, while surgery offers a one-time treatment option. Identification of the ampulla and a duodenal resection sparing ampullary area becomes difficult in larger lesions of the 2nd part of the duodenum. Passage of a catheter from cystic duct through common bile duct to duodenum aids in identification of the ampullary area and is helpful in performing a local/wedge resection of the duodenum containing adenoma without injuring ampullary orifice.

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Duodenal adenomas carry malignant potential.

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Found sporadically or with familial syndromes.

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Surgery offers one time treatment options for larger lesions.

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Isolating the ampullary orifice through catheterization of the cystic duct is useful.

Endoscopic Treatment for Superficial Nonampullary Duodenal Tumors

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.

Initial multicenter experience with nitrous oxide cryoballoon for treatment of flat duodenal adenomas (with video)

BACKGROUND AND AIMS

EMR is the preferred endoscopic therapy for duodenal adenomas (DAs) but is associated with an overall adverse event rate of 26%. Cryotherapy using a Cryoballoon Focal Ablation System (CbFAS) can safely and effectively eradicate esophageal intestinal metaplasia. We report our first experience with cryoballoon ablation for treatment of flat DAs.

METHODS

This was an American, multicenter, retrospective study involving 5 centers. DAs (Paris 0-IIa and 0-IIb) were treated with nitrous oxide for 5 to 12 seconds using CbFAS. Follow-up EGD was performed at 3 to 12 months.

RESULTS

Seventeen DAs (mean size, 22.7 ± 14.3 mm; 12 tubular, 5 tubulovillous) from 13 patients (mean age, 66.5 ± 9.99 years; 61.5% males) were included in the study. Thirteen of 17 DAs (76.5%) had failed previous treatment, and 4 of 17 (23.5%) were treatment naÏve. All procedures were technically successful and achieved a >50% decrease in size after cryoballoon ablation There was no increase in size or progression of disease for any lesions. Overall, treatment was completed in 15 of 17 patients, and recurrence-free survival was achieved in 12 of 17 (71%) after a median follow-up of 15.5 months (interquartile range [IQR], 6.8-19.4). The median cryoablation time per polyp was 4 minutes (IQR, 1-7.5 minutes), and the median total procedure time was 25 minutes (IQR, 22-30.5 minutes). There were no intra- or postprocedural adverse events.

CONCLUSIONS

Nitrous oxide cryoballoon ablation of nonpolypoid DAs is feasible, with promising safety and efficacy.

American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in familial adenomatous polyposis syndromes

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.

Clinical outcomes of endoscopic resection for superficial non-ampullary duodenal tumors

Background and study aims  Because superficial non-ampullary duodenal epithelial tumors (SNADETs) are relatively rare, studies evaluating the outcomes of endoscopic resection (ER) for SNADETs are limited. Therefore, this study aimed to evaluate the clinical validity of ER for SNADETs. Patients and methods  The study participants included 163 consecutive patients (108 men; mean age, 61.5 ± 11.3 years) with 171 SNADETs, excluding patients with familial adenomatous polyposis resected by ER, at Hiroshima University Hospital between May 2005 and September 2016. Clinicopathological features and the outcomes of ER for 171 cases were retrospectively analyzed. Additionally, the prognosis of 135 patients with more than 12 months' follow-up was analyzed. Results  Mean diameter of SNADETs was 10.7 ± 7.2 mm. Most of the SNADET cases were classified as category 3 (71 %, 121/171), but some were category 5 (2 %, 3/171). En bloc resection rates were 93 % (146/157), 100 % (7/7), and 86 % (6/7) in endoscopic mucosal resection (EMR), polypectomy, and in endoscopic submucosal dissection (ESD) cases, respectively. Complete resection rates were 90 % (141/157), 100 % (7/7), and 71 % (5/7) in EMR, polypectomy, and ESD cases, respectively. Emergency surgery was performed in two patients with intraoperative perforation and in two with delayed perforation without artificial ulcer bed closure after ER. Since endoscopic closure of ulcer by clipping was performed, delayed perforation has not occurred. Local recurrence occurred in 1.2 %, but no metastasis to lymph nodes or other organs occurred after ER. No patient died of primary SNADETs. Conclusion  Our data supported the clinical validity of ER for SNADETs. However, delayed perforation should be given much attention.

Comparative analysis of ESD versus EMR in a large European series of non-ampullary superficial duodenal tumors

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.

ESD versus EMR in non-ampullary superficial duodenal tumors: a systematic review and meta-analysis

BACKGROUND AND STUDY AIMS

 Endoscopic submucosal dissection (ESD) has been developed as an option for treatment of esophageal, gastric and colorectal lesions. However, there is no consensus on the role of ESD in duodenal tumors.

METHODS

 This systematic review and meta-analysis compared ESD and endoscopic mucosal resection (EMR) in sporadic non-ampullary superficial duodenal tumors (NASDTs), including local experience. We conducted a search in PubMed, Scopus and the Cochrane library up to August 2017 to identify studies that compared both techniques reporting at least one main outcome (en-bloc/complete resection, local recurrence). Pooled outcomes were calculated under fixed and random-effect models. Subgroup analyses were conducted.

RESULTS

 A total of 753 patients presenting with 784 NASDTs (242 ESD, 542 EMR) in 14 studies were included. Tumor size (MD: 5.88, [CI95 %: 2.15, 9.62], P  = 0.002, I 2  = 79 %) and procedure time (MD: 65.65, [CI95 %: 40.39, 90.92], P  < 0.00001, I 2  = 88 %) were greater in the ESD group. En-bloc resection rate was significantly higher in Asian studies (OR: 2.16 [CI95 %: 1.15, 4.08], P  = 0.02, I 2 : 46 %). ESD provided a higher complete resection rate (OR: 1.63 [I95 %: 1.06, 2.50], P  = 0.03, I 2 : 59 %), but there was no risk difference in the risk of local recurrence (RD: - 0.03 [CI95 %: - 0.07, 0.01], P  = 0.15, I 2 : 0 %) or delayed bleeding. ESD was associated with an increased number of intraoperative perforations [RD: 0.12 (CI95 %: 0.04, 0.20), P  = 0.002, I 2 : 56 %] and emergency surgery for delayed perforations. The inclusion of eligible studies was limited to retrospective series with inequalities in comparative groups.

CONCLUSIONS

 Duodenal ESD for NASDTs may achieve higher en-bloc and complete resections at the expense of a greater perforation rate compared to EMR. The impact on local recurrence remains uncertain.

Novel Approach for Endoscopic Management of Duodenal Injury during Perirenal Infected Haematoma Drainage after Shock-Wave Lithotripsy

Background. Gaining percutaneous access during percutaneous nephrolithotomy (PNL) can be complicated with the bowel injury. We report a novel approach of management of duodenal injury complicating percutaneous drainage of infected haematoma after Shock-Wave Lithotripsy (SWL). Case Presentation. A 57-year-old patient with the 15 mm right pelvic kidney stone underwent uneventful SWL. Patient visited emergency department 3 days later with high fever and chills with severe right flank pain. CT urography revealed lower pole kidney injury with signs of infected hematoma due to low attenuation areas but without signs of obstruction or urine leakage. Infected haematoma was drained percutaneously under ultrasound and X-ray control and a pigtail catheter 10 Fr was left beneath the lower pole of the right kidney. Postoperatively duodenal injury was suspected due to amber color, low creatinine, and high bilirubin level in the drainage output. CT demonstrated that the pigtail of the drain had entered the second part of the duodenum. Catheter was withdrawn and defect of the duodenal wall was stapled with four staples endoscopically. After 2 days of fasting patient was allowed to start oral food intake and was discharged on the 5th day. Conclusion. Injury of the duodenum during percutaneous kidney manipulation is an extremely rare complication. Conservative management consisting of endoscopic stapling of the duodenal wall defect is a safe and feasible approach to expediting the recovery of the patient.

Endoscopic and surgical management of nonampullary duodenal neoplasms

BACKGROUND

Sporadic nonampullary duodenal neoplasms (SNADN) can have malignant potential for which endoscopic and surgical resections are offered. We report combined gastroenterologic and surgical experience for treatment of SNADN, including endoscopic mucosal resection (EMR) and pancreas-preserving partial duodenectomy (PPPD).

METHODS

We retrospectively reviewed 121 consecutive patients, who underwent 30 PPPDs and 91 EMRs for mucosal and submucosal SNADN. Decision to undergo EMR or surgical resection was based on expert endoscopist and surgeon discretion including multidisciplinary tumor board review. Main outcomes were recurrence rate of neoplasia and adverse events requiring hospital admission or prolonged care. EMRs were performed with submucosal lifting followed by snare resection. PPPD included total duodenectomy, supra-ampullary PPPD for neoplasms proximal to the ampulla, and infra-ampullary PPPD for lesions distal to the ampulla. Follow-up data were available for 65% of EMR and 73% of surgical patients.

RESULTS

Surgically resected neoplasia was larger with more advanced neoplasia and submucosal lesions. En bloc resection was achieved in all surgical resections and in 53% of EMRs. Post-EMR, mucosal and submucosal neoplasia recurred in 32 and 0%, respectively, including five neoplasms (26%) after an initial negative esophagogastroduodenoscopy. All recurrences were treated endoscopically. Complications occurred in 14 endoscopically and eight surgically treated patients, none requiring surgical intervention.

CONCLUSIONS

Post-EMR patients had higher recurrence of mucosal neoplasia, whereas submucosal neoplasms, mainly carcinoid, did not recur. Polyp size and positive resection margin were not associated with neoplasia recurrence. Patients with SNADN could benefit from a multidisciplinary approach to stratify the optimal treatment based on local expertise.

Endoscopic closure after intraluminal surgery

Endoscopic submucosal dissection is established as a curative endoscopic method for gastrointestinal epithelial neoplasms with a high possibility of complete en bloc resection; however, postoperative adverse events of bleeding and delayed perforation remain. To prevent or minimize them, several techniques for endoscopic mucosal closure have been introduced, such as using endoscopic clips, combined use of hemoclips and supplement devices, and specially designed endoscopic suturing devices. Furthermore, endoscopic full-thickness suturing technique for gastrointestinal wall defect has been developed based on the concept in natural orifice transluminal endoscopic surgery and endoscopic full-thickness resection. Several closure techniques, including over-the-scope clip, threaded bars inserted in a hollow needle, stitches or staplers, and a curved needle and thread are reported. Secure closure of the iatrogenic defect may further expand the range of therapeutic endoscopy. Accumulation of evidence for the efficacy of endoscopic closure and establishment of these techniques are desired.

Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes

BACKGROUND AND AIMS

Large sporadic duodenal adenomas are uncommon but they harbor malignant potential, which requires consideration of definitive treatment. EMR is gaining acceptance as an effective and safe alternative to high-risk surgical procedures, but data on long-term outcomes are limited. Herein we describe the short- and long-term outcomes of these lesions in a tertiary referral center.

METHODS

Prospectively collected data were analyzed to identify risk factors for adverse events and outcomes. Patient demographics, lesion characteristics, and procedural technical data were collected.

RESULTS

From 2007 to 2015, 106 adenomas ≥10 mm were resected (mean patient age, 69 years; 54% male; median size, 25 mm; interquartile range [IQR], 19-40). Complete endoscopic resection was achieved in 96%. Intraprocedural bleeding occurred in 43% of cases and was associated with lesion size (P < .001), number of resected specimens (P = .003), and longer procedures (P = .001). Delayed bleeding occurred in 15% (56% did not require active intervention) and was associated with lesion size (P = .03). Perforation occurred in 3 patients. The 30-day mortality was 0%. Median follow-up was 22 months (IQR, 7-45). Histologically proven adenoma recurrence was identified and treated in 12 of 83 patients (14.4%) on first surveillance endoscopy. For the 53 patients for whom follow-up ≥12 months was available (median follow-up, 36 months; IQR, 24-51), 48 patients (90.6%) were free of adenoma and considered cured.

CONCLUSIONS

In a tertiary referral center, endoscopic resection of duodenal adenomas is a safe and effective alternative to surgery. Lesion size is strongly associated with adverse events, particularly intraprocedural bleeding and delayed bleeding. Good long-term outcomes are demonstrated.

Safety and efficacy of EMR for sporadic, nonampullary duodenal adenomas: a single U.S. center experience (with video)

BACKGROUND AND AIMS

EMR is increasingly used for resection of sporadic, nonampullary duodenal adenomas (SNDAs), but there are no guidelines for the management of these lesions. The aims of this study were to evaluate the safety and efficacy of EMR exclusively for SNDAs and to determine the factors predictive of outcomes.

METHODS

We performed a retrospective review of patients with SNDAs referred for endoscopic therapy from 2006 to 2013. The outcomes studied were successful endoscopic resection, major adverse events, early and late recurrences, and clinical remission.

RESULTS

Sixty-eight patients with SNDAs were included and 51 (75%) underwent EMR. The mean adenoma size was 22.0 ± 8.9 mm. Successful resection was achieved in 49 of 51 patients (96.1%), and major adverse events were noted in 8 of 51 patients (15.7%). Early and late recurrences were noted in 25.6% and 5.2% of patients, respectively, and were treated endoscopically. Clinical remission was achieved in 89.7% of patients after a median follow-up of 15 months. Presence of villous histology was associated with increased recurrence (P = .019), but no association of recurrence was noted with other endoscopic features or resection technique. Large adenoma size (P = .0057) and need for intraprocedural hemostasis (P = .006) were associated with increased adverse events, but no association of adverse events was noted with location or resection technique.

CONCLUSIONS

Large duodenal adenomas can be effectively managed with EMR at a referral center with experienced endoscopists. However, EMR has a significant recurrence rate, especially early recurrence, and the risk of adverse events is not negligible. Endoscopic therapy is successful in managing recurrent adenomas.

Endoscopic resection for duodenal subepithelial tumors: a single-center experience

BACKGROUND

Subepithelial tumors (SETs) in the gastrointestinal tract are often incidentally found during endoscopic examinations. Although the utility and safety of endoscopic resection (ER) of SETs in the esophagus and stomach have been described, data about the ER of duodenal SETs remain scant. Therefore, we aimed to investigate the clinical outcomes associated with the ER of duodenal SETs and to assess possible predictive factors for incomplete resection.

METHODS

We conducted a retrospective observational study of 62 patients (64 lesions) that underwent ER of duodenal SETs between June 2005 and December 2015 at the Pusan National University Hospital. The therapeutic outcomes from ER and procedure-related complications were analyzed.

RESULTS

Endoscopic mucosal resection (EMR) was performed in 38 tumors, EMR with a ligation device (EMR-L) in 18 and endoscopic submucosal dissection (ESD) in 8. The overall en bloc resection and complete ER rates were 96.9 % (62/64) and 100 % (64/64), respectively. The complete pathologic resection rate was 76.6 % (49/64). Multivariate logistic regression analyses determined that the macroscopic type (Yamada type I or II; odds ratio [OR] 6.460, 95 % confidence interval [CI] 1.569-37.458, p = 0.027) and the treatment method (ESD; OR 7.178, 95 % CI 1.291-39.323, p = 0.024) were independently associated with incomplete pathologic resection. The procedure-related bleeding and perforation rates were 6.3 % and 4.7 %, respectively. No recurrences were observed in patients who had undergone complete ER at a median follow-up period of 20 months (range 6-112 months).

CONCLUSION

ER is an effective, safe, and feasible treatment for duodenal SETs, especially when the SET is located in the deep mucosal layer and/or the submucosal layer.

Management of a large mucosal defect after duodenal endoscopic resection

Duodenal endoscopic resection is the most difficult type of endoscopic treatment in the gastrointestinal tract (GI) and is technically challenging because of anatomical specificities. In addition to these technical difficulties, this procedure is associated with a significantly higher rate of complication than endoscopic treatment in other parts of the GI tract. Postoperative delayed perforation and bleeding are hazardous complications, and emergency surgical intervention is sometimes required. Therefore, it is urgently necessary to establish a management protocol for preventing serious complications. For instance, the prophylactic closure of large mucosal defects after endoscopic resection may reduce the risk of hazardous complications. However, the size of mucosal defects after endoscopic submucosal dissection (ESD) is relatively large compared with the size after endoscopic mucosal resection, making it impossible to achieve complete closure using only conventional clips. The over-the-scope clip and polyglycolic acid sheets with fibrin gel make it possible to close large mucosal defects after duodenal ESD. In addition to the combination of laparoscopic surgery and endoscopic resection, endoscopic full-thickness resection holds therapeutic potential for difficult duodenal lesions and may overcome the disadvantages of endoscopic resection in the near future. This review aims to summarize the complications and closure techniques of large mucosal defects and to highlight some directions for management after duodenal endoscopic treatment.

Safety of endoscopic resection for duodenal subepithelial lesions with wound closure using clips and an endoloop: an analysis of 68 cases

BACKGROUND

Endoscopic removal of a duodenal lesion is still considered to be a challenging procedure that can be fraught with potentially serious complications, specifically perforation or delayed bleeding. This study was to assess the safety of endoscopic resection for duodenal subepithelial lesions (SELs) with wound closure using clips and an endoloop.

METHODS

From October 2010 to July 2015, a total of 68 consecutive patients with duodenal SELs were treated with endoscopic resection with wound closure using clips and an endoloop. The main outcome measures considered were the incidence of complete resection, perioperative perforation, delayed perforation, delayed bleeding, residual lesions, and lesion recurrence.

RESULTS

Complete resection was successfully achieved for all 68 patients. The median lesion size was 1.7 cm. The median procedure time was 62 min. The mean hospital stay was 5.5 days. During the procedure, five patients developed perioperative perforations (7.4 %) and no patients developed delayed bleeding, delayed perforation, or other serious complications. The five patients with perioperative perforations recovered after conservative treatment. The perioperative perforation rate was significantly higher for lesions originating in the muscularis propria layer (18.2 %) than in the submucosal layer (2.2 %; p < 0.05). No residual or recurrent lesions were detected during the follow-up period (median: 27 months).

CONCLUSIONS

Endoscopic resection with wound closure using clips and an endoloop is an effective and reasonably safe therapeutic method for treating/removing duodenal SELs when managed by an experienced endoscopic team, and it can provide an alternative treatment option for patients with duodenal SELs.

[Primary Non-ampullary Duodenal Adenocarcinoma: A Single-center Experience for 15 Years]

BACKGROUND/AIMS

Primary non-ampullary duodenal adenocarcinomas (PNADAs) comprise <œ0.3% of gastrointestinal malignancies. The rarity of PNADA and poorly defined natural history often leads to a delayed correct diagnosis. This study was conducted to evaluate the clinical characteristics of PNADA and to identify its prognostic factors.

METHODS

Data were collected by retrospectively reviewing the medical records of patients with PNADA managed at Gyeongsang National University Hospital from January 2000 to December 2014. Demographic, clinical, endoscopic, and pathological variables were investigated, and factors related to survival were analyzed.

RESULTS

Twenty-seven patients with PNADA were identified, and their median age was 64.9±13.6 years with 16 (59.3%) being male. The majority of patients (25/27, 92.6%) were initially diagnosed during upper endoscopy with biopsies. The tumor was located on the 1st or 2nd portion of duodenum in 92.6% (25/27) of patients. At the time of diagnosis, 85.2% (23/27) had advanced diseases (stage III or IV); 48.2% (13/27) had distant metastasis. Median survival time was 12 months (1-93 months). One and 3-year survival rates were 48.1% and 33.3%, respectively. On multivariable analysis, total bilirubin ≥2 mg/dL (OR, 85.28; 95% CI, 3.77-1,938.79; p=0.005) and distant metastasis (OR, 26.74; 95% CI, 3.13-2,328.14; p=0.003) at the time of diagnosis were independent poor prognostic factors.

CONCLUSIONS

The majority of patients were diagnosed at an advanced stage. Presence of distant metastasis was independent prognostic factor of PNADA together with elevated total bilirubin.

[Endoscopic Resection of Sporadic Non-ampullary Duodenal Neoplasms: A Single Center Study]

BACKGROUND/AIMS

Sporadic non-ampullary duodenal neoplasms are rare and optimal treatment for these lesions remains undefined. Endoscopic resection of duodenal neoplasms is widely used recently and it is an alternative treatment strategy to surgical excision. This study aimed to evaluate the safety and efficacy of endoscopic resection of duodenal neoplasms and to determine its outcomes.

METHODS

Patients who underwent endoscopic resection for non-ampullary duodenal neoplasms between January 2005 and December 2014 were analyzed retrospectively. Data including size, morphology, histology, location and endoscopic procedural technique were reviewed. The main outcome measurements were success rate, complication, recurrence and follow-up assessments.

RESULTS

The study included 33 patients with duodenal neoplasms. The mean size of resected lesion was 8.58 mm. The results of histologic examination were as follows: 23 (69.7%) adenomas, 2 (6.1%) adenocarcinoma, 3 (9.1%) Brunner's gland tumor and 3 (9.1%) neuroendocrine tumor. Tubular adenoma was the most common type (63.6%) of non-ampullary duodenal neoplasms. Eighteen (54.5%) lesions were found in the second portion of the duodenum, and 10 (30.3%) lesions on bulb and 3 (9.1%) lesions on superior duodenal angle. Of the 33 cases, 32 (97.0%) were managed by endoscopic mucosal resection technique during a single session and one case was managed by endoscopic submucosal dissection (ESD). One episode of perforation occurred after ESD. During a median follow-up period of 5.76 months, recurrence was observed in only one case of in a patient with tubular adenoma.

CONCLUSIONS

Endoscopic resection of duodenal neoplasm is a safe and effective treatment modality that can replace surgical resection in many cases. Careful endoscopic follow-up is essential to manage recurrence or residual lesions.

Nonampullary duodenal adenoma: Current understanding of its diagnosis, pathogenesis, and clinical management

Nonampullary duodenal adenomas are relatively common in familial adenomatous polyposis (FAP), but nonampullary sporadic duodenal adenomas (SDAs) are rare. Emerging evidence shows that duodenal adenomas, regardless of their anatomic location and whether they are sporadic or FAP-related, share morphologic and molecular features with colorectal adenomas. The available data suggest that duodenal adenomas develop to duodenal adenocarcinomas via similar mechanisms. The optimal approach for management of duodenal adenomas remains to be determined. The techniques for endoscopic resection of duodenal adenoma include snare polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and argon plasma coagulation ablation. EMR may facilitate removal of large duodenal polyps. Although several studies have reported cases of successful ESD for duodenal adenomas, the procedure is technically difficult to perform safely because of the anatomical properties of the duodenum. Although current clinical practice recommends endoscopic resection of all large duodenal adenomas in patients with FAP, endoscopic treatment is usually insufficient to guarantee a polyp-free duodenum. Surgery is indicated for FAP patients with severe polyposis or nonampullary SDAs or FAP-related polyps not amenable to endoscopic resection. Further studies are needed to develop newer endoscopic techniques to guide diagnostic and therapeutic decisions for future management of nonampullary duodenal adenomas.