Clinical outcomes of endoscopic mucosal resection for large superficial nonampullary duodenal epithelial tumor: a single-center study

Abstract

Background and aim: Endoscopic mucosal resection (EMR) of superficial nonampullary duodenal epithelial tumors (SNADETs) is challenging, and to date, only a few studies assessed the clinical outcomes of EMR in the duodenum. The aim of this study was to evaluate the efficacy and safety of EMR for the treatment of SNADETs >10 mm.

Patients and methods: This is a single-center retrospective study reporting data from a cohort of consecutive patients undergoing EMR of large (>1 cm) SNADETs between January 2017 and December 2021.

Results: A total of 81 patients with 83 lesions underwent EMR (70 conventional EMR, 13 underwater EMR). The median size was 20 mm (range: 10-60 mm). The mean procedure time was 45 ± 30 min, and the en-bloc resection rate was 47%. In all patients, SNADETs were successfully removed (i.e. technical success). Delayed bleeding occurred in 5 (6%) of EMRs. One delayed perforation occurred, which was managed surgically. Recurrence rate was 20% with a median follow-up period of 20.5 months. Recurrence was detected at the first endoscopic follow-up in 88% of cases, and all recurrences were successfully treated endoscopically. Lesion size ( P = 0.04), previous endoscopic resection ( P = 0.05), and piecemeal resection ( P = 0.05) were independent risk factors of local recurrence after EMR on multivariate-adjusted analysis.

Conclusion: Large duodenal adenomas can be effectively managed by EMR. However, duodenal EMR of large lesions carries a significant risk of early recurrence, with a nonnegligible risk of adverse events. Lesion dimension, piecemeal resection, and previous endoscopic resection were associated with a higher recurrence rate. Close endoscopic follow-up is recommended given the high incidence of early recurrence, which can be successfully treated endoscopically.

Keywords: SNADETs; duodenum; mucosal resection; underwater.

Fig. 1.

Underwater endoscopic mucosal resection (u-EMR) with partial submucosal injection for a superficial nonampullary duodenal epithelial tumor (SNADET). (a) A 15-mm flat elevated lesion is located on descending part of the duodenum. (b) Virtual Chromoendoscopy was used to clarify the border of the tumor. (c) Partial submucosal injection with saline and indigo carmine was performed on the distal edge of the lesion and the lumen was filled with saline. (d, e) The lesion was resected with a 15-mm hot snare in a single piece without any adverse events. (f) The mucosal defect was completely closed with five endoclips. Pathological findings revealed low-grade dysplasia adenoma with free horizontal and vertical margins.