Endoscopic resection of superficial non-ampullary duodenal epithelial tumor

Abstract

Although superficial non-ampullary duodenal epithelial tumor (SNADET) was previously considered a rare disease, in recent years, the opportunities to detect and treat SNADET are increasing. Considering the high morbidity of pancreatoduodenectomy, endoscopic resection can be a treatment option that preserves the organs and contributes maintain patients' quality of life. Endoscopic mucosal resection (EMR) is a standard treatment for relatively small lesions in gastrointestinal tracts, however, it is difficult because submucosal fibrosis frequently occurs due to the previous biopsy. Recently, some modified EMR techniques including underwater EMR (UEMR) and cold polypectomy (CP) have been proposed. In UEMR, the duodenal lumen is filled with water or saline and resected the targe lesion with a snare without injection into the submucosa. It would be a treatment option that could reduce candidates for ESD especially SNADET less than 20 mm. CP was reported as a safe and convenient means for SNADET. It would also be one of the standard treatments for diminutive lesions, though there remain some concerns on its resectability. ESD for SNADET is technically challenging, especially with an extremely high risk of adverse event (AE) with a reported bleeding rate of more than 20% and perforation rate up to about 40%. However, modified treatment techniques including the water pressure method and pocket creation method have been reported to potentially contribute to improving outcomes of ESD. Moreover, accumulated evidence shows closing the mucosal defect significantly reduces delayed adverse events after duodenal endoscopic treatments. Further studies are warranted to elucidate curative criteria, long-term outcomes, and appropriate surveillance strategy.

Keywords: duodenum; endoscopic resection; outcomes.

FIGURE 1

Underwater endoscopic mucosal resection (EMR) for a superficial non‐ampullary duodenal epithelial tumor (SNADET). (a) A 15 mm‐flat elevated lesion is located on descending part of the duodenum. (b, c) The lesion was captured by a snare after filling the lumen with normal saline. (d) The lesion was resected in a single piece without any adverse events. (e) The mucosal defect was completely closed using endoclips. (f) Resected specimen. Pathological findings revealed low‐grade adenoma with free horizontal and vertical margins

FIGURE 2

Underwater endoscopic mucosal resection (EMR) with partial submucosal injection for a superficial non‐ampullary duodenal epithelial tumor (SNADET). (a, b) A 15 mm‐flat elevated lesion is located on descending part of the duodenum. (c) Hyaluronic acid was injected only distal edge of the lesion after filling the lumen with normal saline. (d, e, f) The lesion was resected in a single piece without any adverse events. (g) Resected specimen. Pathological findings revealed low‐grade adenoma with free horizontal and vertical margins

FIGURE 3

Cold snare polypectomy for multiple adenomatous lesions in patients of familial adenomatous polyposis syndrome. (a) Multiple adenomatous lesions were found in descending duodenum. (b) Lesions were resected by cold snare polypectomy. (c) Post resection mucosal defects. The patient was discharged a day after the procedure without any adverse event

FIGURE 4

Endoscopic submucosal dissection (ESD) using the water pressure method. (a) A 40 mm‐flat elevated lesion was found in descending duodenum. (b, c) Mucosal incision. (d, e) Hitting the water to submucosa contributed to improved visibility of dissecting area. (f) The lesion was resected without any adverse event

FIGURE 5

String clip suturing method for a large mucosal defect. (a) A 40 mm‐flat elevated lesion was found in descending duodenum. (b, c) The wound was approximated by pulling a string tightened to the clip. (d, e) The string was cut by scissors forceps and additional clips were deployed. (f) The wound was completely closed

FIGURE 6

Complete closure of the mucosal defect in the case with intraprocedural perforation. (a) A 5 mm perforation occurred during submucosal dissection. (b) The wound was approximated by pulling string tightened to the clip. (c) The whole mucosal defect was completely closed. The post‐procedural clinical course was non‐eventful and the patient was discharged post procedural day 4

FIGURE 7

Endoscopic naso‐biliary and naso‐pancreatic drainage (ENBPD) in the case with delayed perforation. (a) Delayed perforation occurred post 2 days after duodenal endoscopic submucosal dissection (ESD). (b, c) We tried to close the perforation with a clip, but due to the fragility of the tissue, the perforation was rather enlarged as a result. (d) Perforated area covered with PGA sheet. (e, f) ENBPD tubes were inserted and the post‐procedural clinical course was non‐eventful without any additional intervention