Endoscopic mucosal resection and endoscopic submucosal dissection in the treatment of sporadic nonampullary duodenal adenomatous polyps

Short- and long-term outcomes of endoscopic submucosal dissection and laparoscopic and endoscopic cooperative surgery for superficial non-ampullary duodenal epithelial tumors

BACKGROUND AND AIMS

This retrospective study aimed to compare the short- and long-term outcomes of endoscopic submucosal dissection and laparoscopic and endoscopic cooperative surgery in patients with superficial non-ampullary duodenal epithelial tumors.

PATIENTS AND METHODS

We investigated consecutive patients with SNADETs > 10 mm in size who underwent ESD (ESD group) or LECS (LECS group) between January 2015 and March 2021. The data was used to analyze the clinical course, management, survival status, and recurrence between the two groups.

RESULTS

A total of 113 patients (100 and 13 in the ESD and LECS groups, respectively) were investigated. The rates of en bloc resection and curative resection were 100% vs. 100% and 93.0% vs. 77.0% in the ESD and LECS groups, respectively, with no significant difference. The ESD group had shorter resection and suturing times than the LECS group, but there were no significant difference after propensity score matching. There were also no differences in the rates of postoperative adverse event (7.0% vs. 23.1%; P = 0.161). The 3-year overall survival (OS) rate was high in both the ESD and LECS groups (97.6% vs. 100%; P = 0.334). One patient in the ESD group experienced recurrence due to liver metastasis; however, no deaths related to SNADETs were observed.

CONCLUSION

ESD and LECS are both acceptable treatments for SNADETs in terms of a high OS rate and a low long-term recurrence rate, thereby achieving a comparable high rate of curative resection. Further studies are necessary to compare the outcomes of ESD and LECS for SNADETs once both techniques are developed further.

Distinct approaches (antecolic and retrocolic) according to tumor location in laparoscopic and endoscopic cooperative surgery for non-ampullary duodenum tumors

AIM

Laparoscopic and endoscopic cooperative surgery for early non-ampullary duodenum tumors (D-LECS) is now noted because of its safety and lower invasiveness. Here, we introduce two distinct approaches (antecolic and retrocolic) according to the tumor location during D-LECS.

METHODS

From October 2018 to March 2022, 24 patients (25 lesions) underwent D-LECS. Two (8%), two (8%), 16 (64%), and five (20%) lesions were located in the first portion, in the second portion to Vater's papilla, around the inferior duodenum flexure, and in the third portion of the duodenum, respectively. The median preoperative tumor diameter was 22.5 mm.

RESULTS

Antecolic and retrocolic approaches were employed in 16 (67%) and 8 (33%) cases, respectively. LECS procedures, such as two-layer suturing after full-thickness dissection and laparoscopic reinforcement by seromuscular suturing after endoscopic submucosal dissection (ESD), were performed in five and 19 cases, respectively. Median operative time and blood loss were 303 min and 5 g, respectively. Intraoperative duodenal perforations occurred in three of 19 cases during ESD; however, they were successfully laparoscopically repaired. Median times until start diet and postoperative hospital stay were 4.5 and 8 days, respectively. Histological examination of the tumors revealed nine adenomas, 12 adenocarcinomas, and four GISTs. Curative resection (R0) was achieved in 21 cases (87.5%). In a comparison of the surgical short outcomes between antecolic and retrocolic approaches, there was no significant difference.

CONCLUSION

D-LECS can be a safe and minimally invasive treatment option for non-ampullary early duodenal tumors, and two distinct approaches according to the tumor location are feasible.

Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of  > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection.

Endoscopic Surveillance and Treatment of Upper GI Tract Lesions in Patients with Familial Adenomatous Polyposis-A New Perspective on an Old Disease

Familial adenomatous polyposis (FAP) is an autosomal dominant disease caused by a germline mutation in the adenomatous polyposis coli (APC) gene. Patients with FAP develop up to thousands of colorectal adenomas as well as lesions in the upper GI tract. In FAP, the upper digestive lesions include gastric fundic gland polyps (FGPs), antrum adenomas, duodenal or small intestinal adenomas, and carcinoma. Patients, after colectomy, are still at significant risk for extracolonic malignancies. Advances in endoscope resolution and optical enhancement technologies allow endoscopists to provide assessments of benign and malignant polyps. For this reason, in the past decades, endoscopic resection techniques have become the first line of treatment in patients with polyps in the upper GI, whereby polyps and even early cancers can be successfully cured. In FAP patients, endoscopic ampullectomy appears to be a safe and effective way of treating patients with ampullary tumors. According to current indications, endoscopic retrograde cholangiopancreatography (ERCP) and stenting of the main pancreatic duct follow ampullectomy.

Efficacy and Safety of Laparoscopic Endoscopic Cooperative Surgery in Upper Gastrointestinal Lesions: A Systematic Review and Meta-Analysis

Background and Aims

Laparoscopic and endoscopic cooperative surgery (LECS) combines advantages of endoscopy and laparoscopy in order to resect upper gastrointestinal lesions. Our aim was to evaluate the efficacy and safety of LECS in patients with EGJ (esophagogastric junction), gastric and duodenal lesions, as well as to compare LECS with pure endoscopic and pure laparoscopic procedures.

Methods

PubMed, Scopus, and ISI Web of Knowledge were searched. Efficacy (R0, recurrence) and safety (conversion rate, procedure and hospitalization time, adverse events, mortality) outcomes were extracted and pooled (odds ratio or mean difference) using a random-effects model. Study quality was assessed with Newcastle-Ottawa Scale and heterogeneity by Cochran's Q test and I² . Subgroup analysis according to location was performed.

Results

This meta-analysis included 24 studies/1,336 patients (all retrospective cohorts). No significant differences were found between LECS and preexisting techniques (endoscopic submucosal dissection (ESD)/laparoscopy) regarding any outcomes. However, there was a trend to shorter hospitalization time, longer procedure duration, and fewer adverse events in LECS versus Laparoscopy and ESD. R0 tended to be higher in the LECS group. Hospitalization time was significantly shorter in gastric versus EGJ lesions (mean 7.3 vs. 13.7 days, 95% CI: 6.6-7.9 vs. 8.9-19.3). There were no significant differences in conversion rate, adverse events, or mean procedural time according to location. There was a trend to higher conversion rate and longer procedure durations in EGJ and higher rate of adverse events in duodenal lesions.

Conclusion

LECS is a valid, safe, and effective treatment option in patients with EGJ, gastric, and duodenal lesions, although existing studies are retrospective and prone to selection bias. Prospective studies are needed to assess if LECS is superior to established techniques.

Key Messages

LECS is safe and effective in the treatment of upper gastrointestinal lesions, but there is no evidence of superiority over established techniques.

Risk Factors of Non-en Bloc Resection and Non-R0 Resection During Endoscopic Resection in the Treatment of Superficial Duodenal Epithelial Lesions

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.

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.

Clinical characteristics of non-ampullary duodenal polyps in the elderly and the outcomes of endoscopic mucosal resection

At present, there are no reports on non-ampullary polyps of the duodenum (NAPDs) in the elderly. The aim of this study was to analyze the clinicopathological features of NAPDs in elderly and non-elderly patients to explore the efficacy and safety of endoscopic mucosal resection (EMR) of NAPDs in the elderly.A total of 110 patients underwent EMR of NAPDs between April 2016 and December 2019. The shape, location, size, postoperative complications, and histopathological types of NAPDs were compared between the elderly group (n = 44) and the non-elderly group (n = 66).Sessile type was the most common form of NAPD in both groups. In the elderly group, the average size of NAPDs was 12.6 ± 3.9 mm. In the non-elderly group, NAPDs had an average size of 10.1 ± 5.8 mm. Complete EMR was performed in both groups. The postoperative complications of EMR did not significantly differ between the 2 groups. Postoperative pathological examination showed that tubular villous adenomas were more common in the elderly group than in the non-elderly group (P = .005), while tubular adenomas were more common in the non-elderly group than in the elderly group (P = .007). Of the 110 patients, 99 completed postoperative follow-up (median follow-up duration, 20.93 months). There were no residual or recurrent lesions.EMR is safe and effective for the treatment of NAPDs in elderly patients.

Preliminary experience of hybrid endoscopic submucosal dissection by duodenoscope for recurrent laterally spreading papillary lesions

BACKGROUND

The management strategies for recurrent ampullary adenoma after endoscopic papillectomy are still controversial. Patients with the recurrent papillary lesions need to receive repetitive endoscopic interventions due to the limitations of conventional endoscopic techniques.

AIM

To assess the feasibility, efficacy, and safety of hybrid endoscopic submucosal dissection (ESD) by duodenoscope for recurrent, laterally spreading papillary lesions.

METHODS

We enrolled two patients with recurrent, laterally spreading, duodenal papillary adenomas with no intraductal extension confirmed by follow-up between March 2017 and September 2018. After marking the resection borders of the lesion using a dual knife, a submucosal cushion was created by injecting a mixture of saline solution, methylene blue, and adrenaline. A total circumferential incision and submucosal excision was performed by dual knife combined with insulated-tip diathermic knife, and then the lesion was ligated and resected using an electric snare. Endoscopic hemostasis was applied during the endoscopic procedures. Moreover, the endoscopic retrograde cholangiopancreatography (ERCP) procedures, including selective cannulation and stent implantation of biliary and pancreatic ducts, were performed. Additionally, we performed endoclip closure for mucosal defect after ESD.

RESULTS

Hybrid ESD using a duodenoscope and biliary and pancreatic stent placement were performed successfully in two patients. The endoscopic size of recurrent papillary lesions was no more than 2 cm. Generally, the average total procedure time was 95.5 min, and the procedure time of ESD and ERCP was 38.5 min and 15.5 min, respectively. No serious complications occurred during the intraoperative and postoperative periods. The histopathological examination revealed tubulovillous adenoma negative for neoplastic extension at the cut margin in both patients. The duodenoscopic follow-up and histopathology of biopsy specimens at 3 mo after ESD showed no residual or recurrent lesions in ampullary areas in both cases. Both cases have been followed up with no recurrence to June 2020.

CONCLUSION

Hybrid ESD by duodenoscope is technically challenging, and may be curative for recurrent, laterally spreading papillary adenomas < 2 cm. It should be performed cautiously in selected patients by experienced endoscopists.

Application of a novel self-assembling peptide to prevent hemorrhage after EMR, a feasibility and safety study

Background

A novel self-assembling peptide (SAP) can be applied to the post-endoscopic mucosal resection (EMR) defect to treat oozing bleedings. It has been suggested to stimulate early healing of damaged vessels. We hypothesized that SAP application could prevent delayed bleeding (DB) after EMR and performed a prospective cohort study to determine feasibility and safety.

Methods

A total of 48 consecutive patients who underwent EMR between June 2018 and August 2019 for large lesions in the esophagus, duodenum (> 1 cm) or colorectum (> 2 cm) were treated with adjuvant SAP application. Duration and ease of SAP application were measured, as well as DB outcome.

Results

The EMR defects of 48 patients were treated with SAP; 17 in the esophagus, 13 in the duodenum and 18 in the colorectum. SAP was easy to apply on the EMR defect with a median duration of 2.0 min. A dose of 3 cc was generally enough to cover a defect between 10 and 50 mm. An exploratory analysis of the prophylactic ability of SAP showed that 15.9% of patients (7/44) treated with SAP still had a DB, mostly in the duodenum (4/11). No adverse events related to gel exposure were reported.

Conclusions

SAP application after EMR was found to be feasible and safe, and did not delay the procedure; however, DB was still relatively common. Future comparative studies are needed to evaluate whether SAP is able to reduce DB after EMR, particularly for lesions with an increased bleeding risk, such as in the duodenum.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07819-7) contains supplementary material, which is available to authorized users.

Combined endoscopy/laparoscopy/percutaneous transhepatic biliary drainage, hybrid techniques in gastrointestinal and biliary diseases

In recent years, a wide range of gastrointestinal endoscopy techniques have been developed, such as endoscopic submucosal dissection (ESD) and endoscopic retrograde cholangiopancreatography (ERCP). Although ESD and ERCP have an important role in gastrointestinal and biliary diseases, each technique has its limitations. Hybrid techniques that combine endoscopic and surgical procedures have emerged that have the advantages of different procedures and negate their limitations at the same time. Laparoscopic endoscopic cooperative surgery and modified laparoscopic endoscopic cooperative surgery combine ESD and laparoscopic techniques to resect submucosal tumors with minimum resection area. Air leak test by intraoperative endoscopy can effectively identify a mechanically insufficient anastomosis and decrease the complication rate. The rendezvous technique that combines percutaneous transhepatic biliary drainage and endoscopy can be performed as a rescue approach for the treatment of biliary obstruction, stenosis and bile duct injuries. For patients with simultaneous presence of stones in the gallbladder and the common bile duct, the laparo-endoscopic rendezvous technique can perform ERCP and laparoscopic cholecystectomy at the same time and reduces the risk of pancreatic injury caused by ERCP. Biliobiliary and bilioenteric anastomosis using magnetic compression anastomosis is another choice for biliary obstruction. The most common used approach to deliver the magnets is by percutaneous-peroral tract. Laparoscopic-assisted ERCP is a safe and highly effective therapy for patients who develop biliary diseases after Roux-en-Y gastric bypass surgery.

Management of perforation related to endoscopic submucosal dissection for superficial duodenal epithelial tumors

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is being performed more frequently as a local treatment for superficial duodenal epithelial tumors (SDETs). However, ESD for SDETs is technically difficult because of specific anatomic features that increase the risk of perforation and often require surgery. This study was performed to evaluate the management of ESD-related perforation in patients with SDETs.

METHODS

Patients who underwent ESD for SDETs from July 2010 to December 2018 were studied. We collected data on complete closure, insertion of endoscopic nasobiliary and pancreatic duct drainage (ENBPD) tubes, and additional interventions. We also evaluated clinical outcomes, including the fasting period, hospital stay, and maximum serum C-reactive protein level.

RESULTS

ESD was completed in 264 patients with SDETs. Perforation was observed in 36 patients, including 4 patients with delayed perforation. Among 32 patients with intraoperative perforation, complete closure was achieved in 13 patients. Compared with patients without complete closure, the fasting period and hospital stay were significantly shorter and the maximum serum C-reactive protein level was significantly lower in patients with complete closure, which were equivalent to those in patients without perforation. In patients without complete closure for mucosal defect, no additional interventions were required when an ENBPD tube was inserted, whereas 2 patients without ENBPD tube insertion underwent additional interventions such as percutaneous drainage and a surgical operation.

CONCLUSIONS

Perforation associated with ESD for SDETs required complex conservative management with complete closure or insertion of an ENBPD tube.

Pathologic Evaluation of Endoscopically Resected Non-Ampullary Duodenal Lesions: A Single Center Experience

OBJECTIVE

Endoscopic resections are increasingly being used for superficial gastrointestinal lesions. However, application of these techniques in the duodenum remains challenging, due to the technical difficulties and high complication rates. This study projects a western tertiary center's experience in the endoscopic treatment and diagnostic workup of 19 cases of non-ampullary duodenal lesions.

MATERIAL AND METHOD

Specimens (12 endoscopic mucosal resections, 6 endoscopic submucosal dissections, and one endoscopic full-thickness resection) were processed following a strict protocol (photographed, mapped digitally and submitted totally) for histopathologic examination. Clinicopathologic characteristics, margin status and follow-up information were analyzed.

RESULTS

The mean age of the 16 patients was 52 years (range: 22-81). Mean lesion size was 1.4 cm (range: 0.3-3.6 cm) for all cases, 2 cm for endoscopic submucosal dissections and 1.1 cm for endoscopic mucosal resections. Mean number of blocks submitted was 4/case. Seven neuroendocrine tumors, 3 tubulovillous adenomas were diagnosed along with nine benign lesions. For endoscopic submucosal dissections, en-bloc and R0 resection rates were 100% (n=6/6) and 83% (n=5/6); for endoscopic mucosal resections, they were 92% (n=11/12) and 83% (n=10/12), respectively. Only one patient had procedure-related late perforation that was managed endoscopically. No mortality was encountered.

CONCLUSION

Duodenal endoscopic resections proved successful, safe and feasible methods in a tertiary center. The pathologist's role is to designate the accurate diagnosis, related histopathologic parameters and margin status. The gross protocol was found to be essential in evaluating specimen margins and orientation, as well as in size measurement. We recommend following a standardized approach including gross photography and digital mapping when handling these specimens, for both diagnostic and data collection purposes.

Endoscopic full-thickness resection of duodenal lesions (with video)

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.

Feasibility and Safety of a Novel Laparoscopic and Endoscopic Cooperative Surgery Technique for Superficial Duodenal Tumor Resection: How I Do It

BACKGROUND

Pancreatoduodenectomy is considered to be a very invasive treatment for early superficial duodenal tumors (SDTs), which have a lower risk of lymph node metastasis. Partial resection of the duodenum with endoscopic submucosal dissection for SDT resection is an attractive technique but it is associated with a high risk of complications. We describe our technique for SDT resection.

METHOD

It includes the following elements: freeing the transverse mesocolon, exposing and mobilizing the second part of the duodenum and the head of the pancreas (Kocher maneuver), confirming the location of the ulcer bed for endoscopic submucosal dissection, and laparoscopic suturing by hand in the seromuscular layer of the duodenum. We performed this technique in 10 patients between March 2015 and March 2017.

RESULTS

The median tumor diameter and resected tissue diameter were 36 (20-54) and 41 (25-60) mm, respectively. Curative resection (R0) with negative margins was achieved for all patients. There were no conversions to open surgery in this series. No postoperative complications were above grade 2 in the Clavien-Dindo classification system. No recurrences were observed during the medium-term follow-up period.

CONCLUSION

This technique is safe and feasible and can be an option for surgical SDT resection.

Giant Brunner's Gland Hyperplasia of the Duodenum Diagnosed by Endoscopic Ultrasonography-guided Fine Needle Biopsy and Treated by Laparoscopic Endoscopic Cooperative Surgery

A 57-year-old female was referred to our department for treatment of a duodenal submucosal tumor (SMT), which had been growing over the last five years. Computed tomography demonstrated a marginally enhanced mass, measuring 36 mm in diameter, containing internal multiple hypovascular areas. Endoscopic ultrasonography-guided fine needle biopsy was performed using a 20-gauge core trap needle, and the specimens showed benign Brunner's glands. She underwent laparoscopic endoscopic cooperative surgery and the SMT was completely removed without any adverse events. Histology of the resected tumor showed Brunner's gland hyperplasia (BGH). BGH is generally a benign lesion. However, an accurate diagnosis is required to avoid overtreatment when it mimics malignancy.

Endoscopic diagnosis and treatment of superficial non-ampullary duodenal tumors

The diagnostic and treatment guidelines of superficial non-ampullary duodenal tumors have not been standardized due to their low prevalence. Previous reports suggested that a superficial adenocarcinoma (SAC) should be treated via local resection because of its low risk of lymph node metastasis, whereas a high-grade adenoma (HGA) should be resected because of its high risk of progression to adenocarcinoma. Therefore, pretreatment diagnosis of SAC or HGA is important to determine the appropriate treatment strategy. There are certain endoscopic features known to be associated with SAC or HGA, and current practice prioritizes the endoscopic and biopsy diagnosis of these conditions. Surgical treatment of these duodenal lesions is often related to high risk of morbidity, and therefore endoscopic resection has become increasingly common in recent years. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are the commonly performed endoscopic resection methods. EMR is preferred due to its lower risk of adverse events; however, it has a higher risk of recurrence than ESD. Recently, a new and safer endoscopic procedure that reduces adverse events from EMR or ESD has been reported.

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.

Endoscopic full-thickness resection of duodenal lesions-a retrospective analysis of 20 FTRD cases

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.

Endoscopic mucosal resection of non-ampullary sporadic duodenal adenomas: a retrospective analysis with long-term follow-up

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.

Real-life evaluation of the safety, efficacy and therapeutic outcomes of endoscopic submucosal dissection in a Western tertiary centre

Background

Endoscopic submucosal dissection (ESD) enables accurate pathological evaluation and low recurrence rates. Large series describing ESD outcomes in Western countries are scarce.

Objective

To evaluate the real-life experience of ESD in a single Western centre.

Methods

Data of all the patients submitted to ESD in our centre were prospectively recorded in a database, from the first procedure in 2011 until May 2017. Feasibility, en bloc and R0 resection rates and safety were assessed.

Results

Three hundred and one ESDs were performed (37 in submucosal lesions) on 283 patients (54% male). Lesions were located in the oesophagus (n = 13), stomach (n = 169), duodenum (n = 4), colon (n = 35) and rectum (n = 80). ESD was technically successful in 292 lesions (97%); among malignant or premalignant epithelial lesions (n = 232), the en bloc resection rate was 91% and, of those, the R0 resection rate was 87% (between 69% in the colon and 93% in the stomach). Two patients needed surgery due to adverse events. Surgery for non-curative ESD was performed in 12 cases (58% without residual lesion). There were 10 perforations, 9 of them closed endoscopically. Mortality was 0%.

Conclusion

Our real-life experience shows that ESD is feasible, safe and effective in Western settings.

Safe management of laparoscopic endoscopic cooperative surgery for superficial non-ampullary duodenal epithelial tumors

Background and study aims  Endoscopic submucosal dissection (ESD) for duodenal tumors results in a high delayed perforation rate due to the thinness of the duodenal wall. In most cases with perforation after duodenal ESD, additional surgery is needed due to severe peritonitis. A newly developed procedure, laparoscopic endoscopic cooperative surgery for duodenal tumors (D-LECS), may help to avoid perforation after ESD. In our institution, patients with superficial non-ampullary duodenal epithelial tumors (SNADET) smaller than 50 mm which could not have en-bloc resection by endoscopic mucosal resection were treated with D-LECS. After a laparoscopic exposure of anterior duodenal wall of second portion, ESD was performed. Laparoscopic suturing from the serosal side of ESD site was performed for reinforcement. There were neither postoperative leakage nor other complications. Therefore, D-LECS can be performed safely and prevent perforation after ESD for SNADET. D-LECS could be selected as a treatment for SNADET which can be cured by ESD.

Laparoscopic and endoscopic co-operative surgery for non-ampullary duodenal tumors

AIM

To assess the safety and feasibility of laparoscopic and endoscopic co-operative surgery (LECS) for early non-ampullary duodenal tumors.

METHODS

Twelve patients with a non-ampullary duodenal tumor underwent LECS at our hospital. One patient had two mucosal lesions in the duodenum. The indication for this procedure was the presence of duodenal tumors with a low risk for lymph node metastasis. In particular, the tumors included small (less than 10 mm) submucosal tumors (SMT) and epithelial mucosal tumors, such as mucosal cancers or large mucosal adenomas with malignant suspicion. The LECS procedures, such as full-thickness dissection for SMT and laparoscopic reinforcement after endoscopic submucosal dissection (ESD) for epithelial tumors, were performed for the 13 early duodenal lesions in 12 patients. Here we present the short-term outcomes and evaluate the safety and feasibility of this new technique.

RESULTS

Two SMT-like lesions and eleven superficial epithelial tumor-like lesions were observed. Seven and Six lesions were located in the second and third parts of the duodenum, respectively. All lesions were successfully resected en bloc. The defect in the duodenal wall was manually sutured after resection of the duodenal SMT. For epithelial duodenal tumors, the ulcer bed was laparoscopically reinforced via manual suturing after ESD. Intraoperative perforation occurred in two out of eleven epithelial tumor-like lesions during ESD; however, they were successfully laparoscopically repaired. The median operative time and intraoperative estimated blood loss were 322 min and 0 mL, respectively. Histological examination of the tumors revealed one adenoma with moderate atypia, ten adenocarcinomas, and two neuroendocrine tumors. No severe postoperative complications (Clavien-Dindo classification grade III or higher) were reported in this series, but minor leakage secondary to pancreatic fistula occurred in one patient.

CONCLUSION

LECS can be a safe and minimally invasive treatment option for non-ampullary early duodenal tumors.

Endoscopic management of mucosal lesions in the gastrointestinal tract

With the increasing role of endoscopy in patient evaluation, more mucosal lesions, including gastric, duodenal and colonic polyps, are encountered during routine examinations. It is imperative for gastroenterologists to become familiar with the endoscopic management of these various gastrointestinal lesions. In this article, various resection techniques will be discussed, including hot/cold forceps polypectomy, hot/cold snare polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection. The article will also discuss the evidence regarding the efficacy and safety of these techniques and the future direction of endoscopic management of mucosal lesions in the gastrointestinal tract.

Approach to the endoscopic resection of duodenal lesions

Duodenal polyps or lesions are uncommonly found on upper endoscopy. Duodenal lesions can be categorized as subepithelial or mucosally-based, and the type of lesion often dictates the work-up and possible therapeutic options. Subepithelial lesions that can arise in the duodenum include lipomas, gastrointestinal stromal tumors, and carcinoids. Endoscopic ultrasonography with fine needle aspiration is useful in the characterization and diagnosis of subepithelial lesions. Duodenal gastrointestinal stromal tumors and large or multifocal carcinoids are best managed by surgical resection. Brunner's gland tumors, solitary Peutz-Jeghers polyps, and non-ampullary and ampullary adenomas are mucosally-based duodenal lesions, which can require removal and are typically amenable to endoscopic resection. Several anatomic characteristics of the duodenum make endoscopic resection of duodenal lesions challenging. However, advanced endoscopic techniques exist that enable the resection of large mucosally-based duodenal lesions. Endoscopic papillectomy is not without risk, but this procedure can effectively resect ampullary adenomas and allows patients to avoid surgery, which typically involves pancreaticoduodenectomy. Endoscopic mucosal resection and its variations (such as cap-assisted, cap-band-assisted, and underwater techniques) enable the safe and effective resection of most duodenal adenomas. Endoscopic submucosal dissection is possible but very difficult to safely perform in the duodenum.