Abbreviation:
ESD (endoscopic submucosal dissection)Endoscopic submucosal dissection (ESD) was developed in Japan and is now widely used around the world.
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Compared with piecemeal EMR, ESD allows en bloc removal of GI tract lesions, decreasing the rate of postprocedural recurrence and allowing adequate histologic interpretation of the resected specimen.4
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However, ESD remains a meticulous, time-consuming, labor-intensive, and difficult-to-learn technique.4
Numerous studies and meta-analyses have confirmed the clinical benefits of ESD for removal of gastric, esophageal, and colonic lesions.
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However, the duodenum remains the most difficult place to perform ESD, and even the experts from well-established ESD centers in Japan remain cautious about performing duodenal ESD because of the exceptional technical difficulties and extremely high rates of adverse events: intraprocedural (13%-50%) and delayed (9%) perforations, bleeding (18%), and need for rescue emergency surgery (14%).7
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If duodenal ESD is so difficult and dangerous, should we stop doing it?Professor Yahagi and his colleagues
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attempted to answer this question by reviewing the various aspects of duodenal ESD in a series of 3 retrospective studies: the first study compared 174 consecutive duodenal ESDs with 146 consecutive duodenal EMRs performed from June 2010 to June 2017. This study demonstrated the advantages of ESD for en bloc resection of large duodenal tumors, especially lesions with suspected malignancy and those that are not amenable to EMR because of such factors as difficult location and poor lifting with submucosal fluid injection.12
However, ESD was associated with a higher rate of perforation (15.5%),12
and the subsequent second publication specifically addressed predictors of technical difficulties and perforations during duodenal ESD.13
Finally, the third study, published in the current issue of Gastrointestinal Endoscopy, concentrates exclusively on the management of perforations during duodenal ESD.14
The authors added an additional 90 procedures and analyzed a total of 264 consecutive duodenal ESDs performed in the same institution from June 2010 to December 2018.14
This study presented very impressive final results. Although the duodenal lesions were large (mean tumor size, 29.8 ± 17.6 mm), and 34.5% had adenocarcinoma, an R0 resection rate was achieved in 83.0% of patients, with a combined perforation rate of 13.6% (intraprocedural perforations in 32 patients [12.1%] and delayed perforations in 4 patients [1.5%]).14
We can learn several important lessons from this study. First, duodenal ESD, even in the most experienced hands, remains a technically difficult and dangerous procedure: an initial 174 duodenal ESDs were done by 6 very experienced endoscopists who had performed over 1000 ESD procedures by the start of this study.
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Despite such extensive ESD experience, 27 perforations occurred in the first 174 cases.12
A comparison of the latest study (36 perforations in 264 patients, 13.6%) with the 2 previous studies demonstrates that growing experience in duodenal ESD decreased the rate of perforation from 17.0% (first 88 patients) to 15.9% (second 88 patients) and, finally, to 8.0% (7 perforations in the last 88 enrolled patients).14
This final rate of perforation is much lower than the previously reported rate of perforations associated with duodenal ESD (21.4%-50.0%),11
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and it is approaching the reported perforation rate during colonic ESD (4.1%-11.6%).6
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The second lesson from the current study is related to management of duodenal perforations: complete closure of intraprocedural perforations with through-the-scope endoscopic clips or a combination of endoscopic clips and a string (string clip suturing technique)
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was achieved in only 13 patients (40.6%).14
Although over-the-scope endoscopic clips are available in Japan, these devices cannot close large mucosal defects and perforations >3 cm. Unfortunately, the Overstitch endoscopic suturing device (Apollo Endosurgery, Austin, Tex, USA) is not currently commercially available in Japan and was not used in this study. The Overstitch endoscopic suturing system allows the creation of separate stitches or a continuous suturing line of various lengths, and it could be an ideal rescue device for closure of duodenal perforations and large mucosal defects after ESD (Video 1, available online at www.giejournal.org).17
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The third lesson from this study addresses the utility of endoscopic retrograde cholangiopancreatography (ERCP) with placement of nasobiliary and nasopancreatic drains to protect the site of duodenal perforation from the damaging effect of bile and pancreatic juice.
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Placement of nasobiliary and nasopancreatic drains was especially important for lesions in the descending part of the duodenum near the papilla of Vater.In conclusion, the study by Fukuhara et al
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represents the largest single-center experience in duodenal ESD in the world and demonstrates that in specialized high-volume centers, the perforation rate during duodenal ESD becomes comparable with perforations during colonic ESD. Because of the high rate of intraprocedural perforations, only endoscopists who have performed a very large number of ESDs should attempt duodenal ESD. Centers specializing in duodenal ESD should also have expertise in the use of the Overstitch endoscopic suturing device and ERCP with the placement of nasobiliary and nasopancreatic drains for successful management of perforations during and after duodenal ESD.Disclosure
Dr Kantsevoy is a co-founder of, shareholder in, and consultant for Apollo Endosurgery; a co-founder of, holder of equity in, and consultant for Endocages; an advisory board member, holder of equity in, and consultant for LumenDi; a participant in active litigation involving LumenR; a consultant for Medrobotics, Medtronic, and Olympus; a holder of equity in Slater Endoscopy; and a holder of equity in and a consultant for Vizballoon.
Supplementary data
- Video 1
Endoscopic suturing closure of a large perforation during duodenal endoscopic submucosal dissection (ESD) A Flat sessile polyp is located in the descending part of the duodenum. Hespan solution with indigo carmine is injected into the submucosal space under the polyp to lift the lesion. Endoscopic submucosal dissection is performed with a DualKnife (Olympus America, Center Valley, Pa, USA), and the polyp is resected en bloc. The specimen is aspirated into the distal attachment (Olympus America) mounted on the distal end of the endoscope and removed. The endoscope is re-inserted into the duodenum, and a large full-thickness perforation is clearly seen at the site of ESD. Bleeding from the edge of the perforation is stopped with a Coagrasper (Olympus America). Then the perforation is completely closed with 1 continuous suture by use of the Overstitch endoscopic suturing device (Apollo Endosurgery, Austin, Tex, USA).
References
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- Management of perforation related to endoscopic submucosal dissection for superficial duodenal epithelial tumorsGastrointestinal EndoscopyVol. 91Issue 5
- PreviewEndoscopic 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.
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