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

Published:March 11, 2016DOI:https://doi.org/10.1016/j.gie.2016.02.049

      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.

      Abbreviations:

      APC (argon plasma coagulation), ASA (American Society of Anesthesiology), DB (delayed bleeding), IPB (intraprocedural bleeding), IQR (interquartile range), LSL-D (lateral spreading lesions of the duodenum), PPI (proton pump inhibitors), PPP (pancreatectomy, pylorus-preserving pancreatectomy), PPPD (pylorus and pancreas-preserving duodenectomy), SDA (sporadic duodenal adenoma), SE (surveillance endoscopy), SE1 (first surveillance endoscopy), STSC (snare tip soft coagulation)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Basford P.J.
        • Bhandari P.
        Endoscopic management of nonampullary duodenal polyps.
        Therap Adv Gastroenterol. 2012; 5: 127-138
        • Culver E.L.
        • McIntyre A.S.
        Sporadic duodenal polyps: classification, investigation, and management.
        Endoscopy. 2011; 43: 144-155
        • Jepsen J.M.
        • Persson M.
        • Jakobsen N.O.
        • et al.
        Prospective study of prevalence and endoscopic and histopathologic characteristics of duodenal polyps in patients submitted to upper endoscopy.
        Scand J Gastroenterol. 1994; 29: 483-487
        • Ghazi A.
        • Ferstenberg H.
        • Shinya H.
        Endoscopic gastroduodenal polypectomy.
        Ann Surg. 1984; 200: 175-180
        • Apel D.
        • Jakobs R.
        • Spiethoff A.
        • et al.
        Follow-up after endoscopic snare resection of duodenal adenomas.
        Endoscopy. 2005; 37: 444-448
        • Honda T.
        • Yamamoto H.
        • Osawa H.
        • et al.
        Endoscopic submucosal dissection for superficial duodenal neoplasms.
        Dig Endosc. 2009; 21: 270-274
        • Kim H.-K.
        • Chung W.C.
        • Lee B.-I.
        • et al.
        Efficacy and long-term outcome of endoscopic treatment of sporadic nonampullary duodenal adenoma.
        Gut Liver. 2010; 4: 373-377
        • Kedia P.
        • Brensinger C.
        • Ginsberg G.
        Endoscopic predictors of successful endoluminal eradication in sporadic duodenal adenomas and its acute complications.
        Gastrointest Endosc. 2010; 72: 1297-1301
        • Miller J.H.
        • Gisvold J.J.
        • Weiland L.H.
        • et al.
        Upper gastrointestinal tract: villous tumors.
        AJR Am J Roentgenol. 1980; 134: 933-936
        • Sellner F.
        Investigations on the significance of the adenoma-carcinoma sequence in the small bowel.
        Cancer. 1990; 66: 702-715
        • Witteman B.J.
        • Janssens A.R.
        • Griffioen G.
        • et al.
        Villous tumours of the duodenum. An analysis of the literature with emphasis on malignant transformation.
        Neth J Med. 1993; 42: 5-11
        • Nonaka S.
        • Oda I.
        • Tada K.
        • et al.
        Clinical outcome of endoscopic resection for nonampullary duodenal tumors.
        Endoscopy. 2015; 47: 129-135
        • Cameron J.L.
        • Riall T.S.
        • Coleman J.
        • et al.
        One thousand consecutive pancreaticoduodenectomies.
        Ann Surg. 2006; 244: 10-15
        • Kemp C.D.
        • Russell R.T.
        • Sharp K.W.
        Resection of benign duodenal neoplasms.
        Am Surg. 2007; 73: 1086-1091
        • Krukowski Z.H.
        • Ewen S.W.
        • Davidson A.I.
        • et al.
        Operative management of tubulovillous neoplasms of the duodenum and ampulla.
        Br J Surg. 1988; 75: 150-153
        • Bourke M.
        Endoscopic mucosal resection in the colon: a practical guide.
        Tech Gastrointest Endosc. 2011; 13: 35-49
        • Ahmad N.A.
        • Kochman M.L.
        • Long W.B.
        • et al.
        Efficacy, safety, and clinical outcomes of endoscopic mucosal resection: a study of 101 cases.
        Gastrointest Endosc. 2002; 55: 390-396
        • Lépilliez V.
        • Chemaly M.
        • Ponchon T.
        • et al.
        Endoscopic resection of sporadic duodenal adenomas: an efficient technique with a substantial risk of delayed bleeding.
        Endoscopy. 2008; 40: 806-810
        • Alexander S.
        • Bourke M.J.
        • Williams S.J.
        • et al.
        EMR of large, sessile, sporadic nonampullary duodenal adenomas: technical aspects and long-term outcome (with videos).
        Gastrointest Endosc. 2009; 69: 66-73
        • Fanning S.B.
        • Bourke M.J.
        • Williams S.J.
        • et al.
        Giant laterally spreading tumors of the duodenum: endoscopic resection outcomes, limitations, and caveats.
        Gastrointest Endosc. 2012; 75: 805-812
        • Bourke M.J.
        Endoscopic resection in the duodenum: current limitations and future directions.
        Endoscopy. 2013; 45: 127-132
        • Kakushima N.
        Treatment for superficial non-ampullary duodenal epithelial tumors.
        World J Gastroenterol. 2014; 20: 12501
        • Basford P.J.
        • George R.
        • Nixon E.
        • et al.
        Endoscopic resection of sporadic duodenal adenomas: comparison of endoscopic mucosal resection (EMR) with hybrid endoscopic submucosal dissection (ESD) techniques and the risks of late delayed bleeding.
        Surg Endosc. 2014; 28: 1594-1600
        • Abbass R.
        • Rigaux J.
        • Al-Kawas F.H.
        Nonampullary duodenal polyps: characteristics and endoscopic management.
        Gastrointest Endosc. 2010; 71: 754-759
        • Min Y.W.
        • Min B.-H.
        • Kim E.R.
        • et al.
        Efficacy and safety of endoscopic treatment for nonampullary sporadic duodenal adenomas.
        Dig Dis Sci. 2013; 58: 2926-2932
        • Seo J.Y.
        • Hong S.J.
        • Han J.P.
        • et al.
        Usefulness and safety of endoscopic treatment for nonampullary duodenal adenoma and adenocarcinoma.
        J Gastroenterol Hepatol. 2014; 29: 1692-1698
        • Veitch A.M.
        • Baglin T.P.
        • Gershlick A.H.
        • et al.
        Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures.
        Gut. 2008; 57: 1322-1329
        • Holt B.A.
        • Bourke M.J.
        Wide field endoscopic resection for advanced colonic mucosal neoplasia: current status and future directions.
        Clin Gastroenterol Hepatol. 2012; 10: 969-979
        • Klein A.
        • Bourke M.J.
        Advanced polypectomy and resection techniques.
        Gastrointest Endosc Clin N Am. 2015; 25: 303-333
        • Takahashi T.
        • Ando T.
        • Kabeshima Y.
        • et al.
        Borderline cases between benignancy and malignancy of the duodenum diagnosed successfully by endoscopic submucosal dissection.
        Scand J Gastroenterol. 2009; 44: 1377-1383
        • Endo M.
        • Abiko Y.
        • Oana S.
        • et al.
        Usefulness of endoscopic treatment for duodenal adenoma.
        Dig Endosc. 2010; 22: 360-365
        • Kakushima N.
        • Ono H.
        • Takao T.
        • et al.
        Method and timing of resection of superficial non-ampullary duodenal epithelial tumors.
        Dig Endosc. 2014; 26: 35-40
        • Goda K.
        • Kikuchi D.
        • Yamamoto Y.
        • et al.
        Endoscopic diagnosis of superficial non-ampullary duodenal epithelial tumors in Japan: multicenter case series.
        Dig Endosc. 2014; 26: 23-29
        • Yoshimura N.
        • Goda K.
        • Tajiri H.
        • et al.
        Endoscopic features of nonampullary duodenal tumors with narrow-band imaging.
        Hepatogastroenterology. 2010; 57: 462-467
        • Kikuchi D.
        • Hoteya S.
        • Iizuka T.
        • et al.
        Diagnostic algorithm of magnifying endoscopy with narrow band imaging for superficial non-ampullary duodenal epithelial tumors.
        Dig Endosc. 2014; 26: 16-22
        • Hirasawa R.
        • Iishi H.
        • Tatsuta M.
        • et al.
        Clinicopathologic features and endoscopic resection of duodenal adenocarcinomas and adenomas with the submucosal saline injection technique.
        Gastrointest Endosc. 1997; 46: 507-513
        • Eswaran S.L.
        • Sanders M.
        • Bernadino K.P.
        • et al.
        Success and complications of endoscopic removal of giant duodenal and ampullary polyps: a comparative series.
        Gastrointest Endosc. 2006; 64: 925-932
        • Belderbos T.D.G.
        • Leenders M.
        • Moons L.
        • et al.
        Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis.
        Endoscopy. 2014; 46: 388-400