Advertisement
Original article Clinical endoscopy: Editorial| Volume 84, ISSUE 4, P697-699, October 2016

Download started.

Ok

Management of duodenal polyps in the era of maximal interventional endoscopy and minimally invasive surgery: a surgical perspective

      Abbreviations:

      HGD (high-grade dysplasia), IC (invasive carcinoma), LAR (local ampullary resection), LSL-D (lateral spreading lesions of the duodenum), PSD (pancreas-sparing duodenal resections), PSPD (pancreas-sparing partial duodenectomy), PSTD (pancreas-sparing total duodenectomy)
      The malignant potential of villous duodenal polyps is estimated to be 47% to 56%, and 43% of patients with familial adenomatous polyposis will experience duodenal tumors.
      • Marcello P.W.
      • Asbun H.J.
      • Veidenheimer M.C.
      • et al.
      Gastroduodenal polyps in familial adenomatous polyposis.
      Early detection and removal of the polyps before they become invasive carcinomas is the best approach for these patients.
      For nonmalignant duodenal lesions, EMR has become the treatment of choice, and surgery is reserved for malignant lesions and benign lesions that are not amenable to EMR. The American Society for Gastrointestinal Endoscopy guidelines from 2006 suggested that surgical resection should be preferred for patients with duodenal adenomatous neoplasia involving more than 33% of the duodenal circumference.
      • Adler D.G.
      • Qureshi W.
      • Davila R.
      • et al.
      The role of endoscopy in ampullary and duodenal adenomas.
      Traditionally, when resection is indicated for these types of lesions, pancreaticoduodenectomy (Whipple procedure) has been the standard procedure of choice. Over the past decade, however, there has been a significant emphasis on decreasing the invasiveness of therapeutic modalities used to resect larger lesions of the GI tract without compromising the completeness of the resection of the lesion. Interventional endoscopists have undertaken resection of larger lesions, and surgeons have developed laparoscopic techniques for pancreas-sparing duodenal resections (PSD). In this issue of Gastrointestinal Endoscopy, Klein et al
      • Klein A.
      • Nayyar D.
      • Bahin F.F.
      • et al.
      Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes.
      report their experience at their tertiary referral centers with EMR of lateral spreading sporadic duodenal adenomas larger than 10 mm. The report clearly illustrates that advanced interventional endoscopic techniques, when done at the right institution by experienced hands, are feasible and safe in the treatment of these lesions.
      The decision-making process regarding which lesions are better approached endoscopically and which should be approached surgically is not discussed in detail in the article. It is clear that malignant and invasive lesions are referred directly to surgery for a Whipple procedure. However, duodenal polyps larger than 10 mm come in different shapes and forms, particularly those larger than 30 mm, which constituted 37% of the lesions in their study.
      • Klein A.
      • Nayyar D.
      • Bahin F.F.
      • et al.
      Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes.
      As surgery has become less invasive and therapeutic endoscopy more aggressive, the decision between surgical and interventional gastroenterology indications in the treatment of these lesions has become less clear. The best treatment option depends on the skills and experience of the treating gastroenterologist or surgeon and on cooperation between the groups. The best success is therefore accomplished by aligning these disease-focused groups to work together rather than in isolation or as dictated by their specialties. As such, the best decision making for the treatment of large lateral spreading lesions of the duodenum (LSL-D) is made by multispecialty focus groups. Additionally, in some instances, an aggressive endoscopic approach may warrant surgical standby backup. Similarly, the extent of resection in pancreas-preserving duodenectomy is contingent on the accuracy of the endoscopic assessment and marking of the lesion.
      In the series by Klein et al,
      • Klein A.
      • Nayyar D.
      • Bahin F.F.
      • et al.
      Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes.
      29 out of 106 patients had a lesion encompassing two thirds or more of the circumference of the duodenum. Margin of resection is an area of concern when we deal with endoscopic or pancreas-preserving surgical duodenectomies. Complete endoscopic resection was defined as no residual visible adenomatous tissue at the end of the EMR.
      • Klein A.
      • Nayyar D.
      • Bahin F.F.
      • et al.
      Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes.
      Even though that definition is acceptable in the presence of a benign lesion, it does present a conundrum when the final pathologic examination shows extensive high-grade dysplasia (HGD) or invasive carcinoma (IC) within the background of a tubulovillous adenoma. Even though the latter is not common (7% in the series by Klein et al
      • Klein A.
      • Nayyar D.
      • Bahin F.F.
      • et al.
      Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes.
      ), when it happens, it probably commits the patient to undergoing a Whipple procedure, particularly if the polyp has been excised in a piecemeal fashion. For those cases, a pancreas-sparing duodenectomy is more likely to provide a better option with a significantly greater chance to accomplish a negative margin. But the feasibility of the procedure can be affected by a prior EMR. The main problem is that polyps harboring HGD or IC are usually not known to do so until after the final pathologic examination is completed. Additionally, histologic examination of margins may be altered by significant cautery artifact, making comments on margin positivity unreliable. When argon plasma coagulation is used at the EMR site, assessment of margin status becomes even less reliable because the remnant surface is being ablated. Furthermore, when piecemeal resections are being dealt with, accurate analysis of margins is basically not feasible. The exact percentage of piecemeal versus en bloc resection is not clearly specified by Klein et al
      • Klein A.
      • Nayyar D.
      • Bahin F.F.
      • et al.
      Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes.
      in their report. However, the authors acknowledge that piecemeal resection was associated with higher rates of histologically proven recurrence at first surveillance endoscopy compared with en bloc resection. The authors also report that the majority of LSL-D lesions (≥30 mm) were removed in a piecemeal fashion. Despite all of this, they report an acceptable recurrence rate of only 14.4% on first surveillance endoscopy, which was amenable to endoscopic repeated excision. Of the patients who underwent repeated excision, only 16.7% had a persistent histologically proven recurrence at second surveillance endoscopy. The rest were considered cured at long-term follow-up.
      In the presence of a known malignancy, a Whipple procedure is the treatment of choice. However, the type of surgical procedure for nonmalignant lesions that are not amenable to endoscopic resection is dependent on the location of the lesion and the presence or absence of ampullary involvement. Pancreas-sparing partial duodenectomy (PSPD) appears to be the best option for lesions not involving the ampullae. The procedure avoids a Whipple procedure by separating the pancreaticoduodenal complex and can be done through a laparoscopic approach. In experienced hands, the morbidity of the procedure is quite acceptable and accomplishes a complete en bloc resection, with negative margins of resection.
      • Stauffer J.A.
      • Raimondo M.
      • Woodward T.A.
      • et al.
      Laparoscopic partial sleeve duodenectomy (PSD) for nonampullary duodenal neoplasms: avoiding a Whipple by separating the duodenum from the pancreatic head.
      A morbidity of 15% and 0 mortality was reported in a study of 20 patients with nonampullary duodenal neoplasia undergoing PSPD at our institution.
      • Puri R.
      • Stauffer J.A.
      • Buchanan M.
      • et al.
      Pancreas sparing partial sleeve duodenectomy (PSD) for non-ampullary duodenal neoplasia.
      The surgical approach was laparoscopic (n = 17), open (n = 2), or hand assisted (n = 1) with either a distal PSPD (n = 13) or a proximal PSPD (n = 7). Pathologic examination of these duodenal lesions revealed tubulovillous adenoma (n = 8), neuroendocrine tumors (n = 4), adenocarcinoma (n = 3), tubular adenoma (n = 2), leiomyoma (n = 1), lymphangiolipoma (n = 1), and chronic duodenitis (n = 1). Morbidity in this series occurred in 3 patients and consisted of delayed gastric emptying in 2 patients; 1 of them had a pancreatic fistula treated with percutaneous drainage and 1 had self-limiting deconditioning. The presence of adenocarcinoma arising from a villous adenoma in the 3 patients in this series was not evident on preoperative endoscopic examination or biopsy. All 3 patients refused to have a subsequent Whipple procedure and have shown no evidence of recurrence on surveillance endoscopic follow-up. As mentioned, the unsuspected presence of carcinoma arising in a duodenal polyp after EMR or PSD presents a quandary because the standard treatment for a malignant lesion of the duodenum is a Whipple procedure. This notion, however, could be argued when we consider that endoscopic resection is considered a curative approach for colonic polyps that present a small-focus adenocarcinoma and have negative margins of resection. Nonetheless, there is no clear evidence that this concept can be transmitted to duodenal malignancies, and the lack of lymph node dissection during EMR or PSD is to be considered. As more of these procedures are being performed, more cases in which preoperative unsuspected carcinoma was found will be reported. Following up those patients who chose not to undergo a Whipple procedure after the EMR or PSD will shed light on this issue in the future.
      For nonmalignant lesions that involve the ampullae and are not amenable to EMR, a surgically performed local ampullary resection (LAR) or a pancreas-sparing total duodenectomy (PSTD) are treatment alternatives to a Whipple procedure. LAR has the advantage of resecting only the area of duodenum around the lesion with preservation of the rest of the duodenum and pancreas. The main disadvantage of the procedure is that the extent of resection is limited, and the margins of resection can be difficult to assess.
      • Clary B.M.
      • Tyler D.S.
      • Dematos P.
      • et al.
      Local ampullary resection with careful intraoperative frozen section evaluation for presumed benign ampullary neoplasms.
      • Asbun H.J.
      • Rossi R.L.
      • Munson J.L.
      Local resection for ampullary tumors. Is there a place for it?.
      PSTD does not have the limitation of LAR. The pylorus and first 1 or 2 centimeters of duodenum can be preserved if they are uninvolved by disease, but the rest of the duodenum is removed, a wide margin of resection being given. The duodenum is completely separated from the pancreas, which affords a complete radial margin of resection.
      • Stauffer J.A.
      • Adkisson C.D.
      • Riegert-Johnson D.L.
      • et al.
      Pancreas-sparing total duodenectomy for ampullary duodenal neoplasms.
      The main issue with both procedures is that they do carry a morbidity associated with the reconstruction of the pancreatic and biliary duct openings. In LAR, the openings are reimplanted into the posterior wall of the duodenum in a radial fashion.
      • Asbun H.J.
      • Rossi R.L.
      • Munson J.L.
      Local resection for ampullary tumors. Is there a place for it?.
      The reconstruction in PSTD is done into a jejunal loop, basically equaling the risks of a reconstruction from a Whipple procedure. The main advantage of PSTD over a Whipple procedure is not so much decreased morbidity but the preservation of the pancreas and the avoidance of a separate bile duct division and reconstruction.
      In conclusion, less invasive treatment options for duodenal lesions have become more prevalent and are being done with good results. Large and complex duodenal lesions are better managed at a tertiary center and dealt with through a multispecialty, disease-focused approach. EMR for large lesions is being performed more often, and by experienced hands, and is the treatment of choice. PSD appears to be the best option for lesions that are not amenable to EMR, particularly when the lesion does not involve the ampulla and can be completely excised through a partial sleeve duodenal resection. The laparoscopic approach requires advanced laparoscopic skills, but it is technically feasible and has shown very good results.

      Disclosure

      The author disclosed no financial relationships relevant to this publication.

      References

        • Marcello P.W.
        • Asbun H.J.
        • Veidenheimer M.C.
        • et al.
        Gastroduodenal polyps in familial adenomatous polyposis.
        Surg Endosc. 1996; 10: 418-421
        • Adler D.G.
        • Qureshi W.
        • Davila R.
        • et al.
        The role of endoscopy in ampullary and duodenal adenomas.
        Gastrointest Endosc. 2006; 64: 849-854
        • Klein A.
        • Nayyar D.
        • Bahin F.F.
        • et al.
        Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes.
        Gastrointest Endosc. 2016; 84: 688-696
        • Stauffer J.A.
        • Raimondo M.
        • Woodward T.A.
        • et al.
        Laparoscopic partial sleeve duodenectomy (PSD) for nonampullary duodenal neoplasms: avoiding a Whipple by separating the duodenum from the pancreatic head.
        Pancreas. 2013; 42: 461-466
        • Puri R.
        • Stauffer J.A.
        • Buchanan M.
        • et al.
        Pancreas sparing partial sleeve duodenectomy (PSD) for non-ampullary duodenal neoplasia.
        Gastroenterology. 2014; 146: S1050
        • Clary B.M.
        • Tyler D.S.
        • Dematos P.
        • et al.
        Local ampullary resection with careful intraoperative frozen section evaluation for presumed benign ampullary neoplasms.
        Surgery. 2000; 127: 628-633
        • Asbun H.J.
        • Rossi R.L.
        • Munson J.L.
        Local resection for ampullary tumors. Is there a place for it?.
        Arch Surg. 1993; 128: 515-520
        • Stauffer J.A.
        • Adkisson C.D.
        • Riegert-Johnson D.L.
        • et al.
        Pancreas-sparing total duodenectomy for ampullary duodenal neoplasms.
        World J Surg. 2012; 36: 2461-2472

      Linked Article