Endoscopic resection of non-ampullary duodenal adenomas: Is cold snaring the promised land?

Due to the high risk of morbidity and mortality associated with surgical resection in this tract,endoscopic resection(ER)has taken the place of surgical resection as the first line treatment for non-ampullary duodenal adenomas.However,due to the anatomical characteristics of this area,which enhance the risk of post-ER problems,ER in the duodenum is particularly difficult.Due to a lack of data,no ER technique for superficial non-ampullary duodenal epithelial tumours(SNADETs)has yet been backed by strong,high-quality evidence;yet,traditional hot snare-based techniques are still regarded as the standard treatment.Despite having a favourable efficiency profile,adverse events during duodenal hot snare polypectomy(HSP)and hot endoscopic mucosal resection,such as delayed bleeding and perforation,have been reported to be frequent.These events are primarily caused by electrocautery-induced damage.Thus,ER techniques with a better safety profile are needed to overcome these shortcomings.Cold snare polypectomy,which has already been shown as a safer,equally effective pro-cedure compared to HSP for treatment of small colorectal polyps,is being increasingly evaluated as a potential therapeutic option for non-ampullary duodenal adenomas.The aim of this review is to report and discuss the early outcomes of the first experiences with cold snaring for SNADETs.

Endoscopic ultrasound evaluation in the surgical treatment of duodenal and peri-ampullary adenomas

AIM:To investigate endoscopic ultrasound(EUS) for predicting depth of mucosal invasion and to analyze outcomes following endoscopic and transduodenal resection.METHODS:Records of 111 patients seen at our institution from November 1999 to July 2011 with the postoperative pathological diagnosis of benign ampullary and duodenal adenomas were reviewed.Records of patients who underwent preoperative EUS for diagnostic purposes were identified.The accuracy of EUS in predicting the absence of muscular invasion was assessed by comparing EUS reports to the final surgical pathological results.In addition,the incidence of the post-operative complications over a period of 30 d and the subsequent long-term outcome(recurrence) over a period of 30 mo associated with endoscopic and transduodenal surgical resection was recorded,compared and analyzed.RESULTS:Among 111 patients with benign ampullary and duodenal adenomas,47 underwent preoperative EUS for 29 peri-ampullary lesions and 18 duodenal lesions.In addition,computed tomography was performed in 18 patients,endoscopic retrograde cholangio-pancreatography in 10 patients and esophagogastroduodenoscopy in 22 patients.There were 43 patients with sporadic adenomas and 4 patients with familial adenomatous polyposis(FAP)/other polyposis syndromes.In 38(81%,P < 0.05) patients,EUS reliably identified absence of submucosal and muscularis invasion.In 4 cases,EUS underestimated submucosal invasion that was proven by pathology.In the other 5 patients,EUS predicted muscularis invasion which could not be demonstrated in the resected specimen.EUS predicted tumor muscularis invasion with a specificity of 88% and negative predictive value of 90%(P < 0.05).Types of resection performed included endoscopic resection in 22 cases,partial duodenectomy in 9 cases,transduodenal ampullectomy with sphincteroplasty in 10 cases and pancreaticoduodenectomy in 6 cases.The main post-operative final pathological results included villous adenoma(n = 5),adenoma(n = 8),tubulovillous adenoma(n = 10),tubular adenoma(n = 20) and hyperplastic polyp(n = 2).Among the 47 patients who underwent resection,8(17%,5 of which corresponded to surgical resection) developed post-procedural complications which included retroperitoneal hematoma,intra-abdominal abscess,wound infection,delayed gastric emptying and prolonged ileus.After median followup of 20 mo there were 6 local recurrences(13%,median follow-up = 20 mo) 4 of which were in patients with FAP.CONCLUSION:EUS accurately predicts the depth of mucosal invasion in suspected benign ampullary and duodenal adenomas.These patients can safely undergo endoscopic or local resection.

Endoscopic resection of carcinoid of the minor duodenalpapilla

We encountered a 65-year-old man with a carcinoid tumor of the minor duodenal papilla. Since he had liver cirrhosis and completely refused surgery, we performed an endoscopic snare papillectomy. The papillectomy was performed successfully without procedure-related complication. The specimens revealed a carcinoid tumor showing that the margin of the tumor was positive. One week later, upper GI endoscopy was performed and the biopsy specimens obtained from base of ulcer showed no neoplastic cells. We performed a duodenoscopy and CT 3, 6 and 18 mo later, and there was no macroscopic or microscopic evidence of tumor recurrence after more than 4 years.

Effect of the manipulation of the duodenal papilla during double balloon enteroscopy

AIM: To determine the hypothesis that inflating the balloons in the duodenal papilla determines changes in the biochemical markers of pancreatitis.METHODS: Four groups of pigs were used: Group papilla(GP), the overtube's balloon was inflated in the area of the papilla; GP + double balloon enteroscopy(GP + DBE), the overtube's balloon was kept inflated in the area of the papilla for 20 min before a DBE; Group DBE(GDBE), DBE was carried out after insuring the balloon's inflation far from the pancreatic papilla; and Group control(GC). Serum concentrations of amylase, lipase and C-reactive protein(CRP) were evaluated. Pancreases were processed for histopathology examination.RESULTS: Main changes occurred 24 h after the procedure compared with baseline levels. Amylase levels increased significantly in GP(59.2% higher) and were moderately higher in groups GP + DBE and GDBE(22.7% and 20%, respectively). Lipase increased in GP and GP + DBE, whereas it hardly changed in GDBE and in GC. CRP increased significantly in GP, GP + DBE and GDBE, while no changes were reported for GC. No statistically significant difference between groups GP and GP + DBE was found for the histopathological findings, except for vacuolization and necrosis of the pancreatic parenchyma that was higher in GP than in GP + DBE.CONCLUSION: The manipulation of the duodenal papilla by the inflated overtube's balloon during DBE causes pancreatic structural damage and increased biochemical markers associated with pancreatitis.

Feasibility and safety of endoscopic cryoablation at the duodenal papilla: Porcine model

AIM: To assess the feasibility and safety of liquid nitrogen spray cryoablation at the duodenal papilla in a porcine model. METHODS: This prospective study protocol was approved by the University of Florida Institutional Animal Care and Use Committee. Six pigs underwent liquid nitrogen spray cryotherapy at the duodenal papilla. Freeze time of 20-s was applied per cycle(4 cycles/session). Survival animals(n = 4) were monitored for adverse events. Hemoglobin, white blood count, liver tests, and lipase were obtained at baseline and post-treatment. EGD was performed on day#7 to evaluate the papilla and for histology. All animals were euthanized and necropsy was performed at the end of the one-week survival period. Feasibility was defined as successful placement of the decompression tube in the duodenum, followed by delivery of spray cryotherapy to the duodenal papilla. Safety was determined by monitoring post-treatment blood tests and clinical course. Treatment effect was defined as endoscopic and histologic changes after cryotherapy. This was established by comparing endoscopic and histologic findings from mucosal biopsies prior to cryotherapy and on post-operative day(POD)#7. Full-thickness specimen was obtained post-mortem to assess depth of injury. RESULTS: Spray cryotherapy was feasible and successfully performed in all 6/6(100%) animals. Cryospray with liquid nitrogen(four 20-s freeze-thaw cycles) at the duodenal papilla resulted in white frost formation at and around the target region. The mean proceduraltime was 54.5 min(range 50-58 min). All six animals studied had stable blood pressure, heart rate, and pulse oximetry measurements during the procedure. There were no significant intra-procedural adverse events. There were no significant differences in hemoglobin, white cell count, liver tests or lipase from baseline to post-cryotherapy. Survival animals were monitored daily post-operatively without any clinical ill effects from the cryotherapy. There was no bleeding, infection, or perforation on necropsy. Endoscopic on POD#7 showed edema and ulceration at the duodenal papilla. On histology, there was loss of crypt architecture with moderate to severe necrosis and acute mixed inflammatory infiltration in each specimen following cryotherapy. The extent of cryogen-induced tissue necrosis(depth of injury) was limited to the mucosa on full-thickness specimen evaluation. CONCLUSION: Endoscopic liquid nitrogen spray cryotherapy is feasible and safe for ablation at the duodenal papilla in a porcine model.

Endoscopic assessment and management of sporadic duodenal adenomas: The results of single centre multidisciplinary management

To review the role of multidisciplinary management in treating sporadic duodenal adenomas (SDA). METHODSSDA managed at North Shore Hospital between 2009-2014 were entered into a prospective database. Pathology, endoscopic and surgical management as well as follow up were reviewed. RESULTSTwenty-eight patients (14 male: Median age 68 years) presented with SDA [18 were classified as non ampullary location (NA), 10 as ampullary location (A)]. All SDA were diagnosed on upper gastrointestinal endoscopy and were imaged with a contrast enhanced CT scan of the chest, abdomen and pelvis. Of the NA adenomas 14 were located in the second part, 2 in the first part and 2 in the third part of the duodenum. Two patients declined treatment, 3 patients underwent surgical resection (2 transduodenal resections and 1 pancreaticoduodenectomy), and 23 patients were treated with endoscopic mucosal resection (EMR). The only complication with endoscopic resection was mild pancreatitis post procedure. Patients were followed with gastroduodenoscopy for a median of 22 mo (range: 2-69 mo). There were 8 recurrences treated with EMR with one patient proceeding to pancreaticodeuodenectomy because of high grade dysplasia in the resected specimen and 2 NA recurrences were managed with surgical resection (distal gastrectomy for a lesion in the first part of the duodenum and a transduodenal resection of a lesion in the third part of the duodenum). CONCLUSIONSDA can be treated endoscopically with minimal morbidity and piecemeal resection results in eradication in nearly three quarters of patients. Recurrent SDA can be treated with endoscopic reresection with surgical resection indicated when the lesions are large (> 4 cm in diameter) or demonstrate severe dysplasia or invasive cancer.

Short-and long-term outcomes of endoscopically treated superficial non-ampullary duodenal epithelial tumors

BACKGROUND It is widely recognized that endoscopic resection(ER) of superficial nonampullary duodenal epithelial tumors(SNADETs) is technically challenging and may carry high risks of intraoperative and delayed bleeding and perforation.These adverse events could be more critical than those occurring in other levels of the gastrointestinal tract. Because of the low prevalence of the disease and the high risks of severe adverse events, the curability including short-and long-term outcomes have not been standardized yet.AIM To investigate the curability including short-and long-term outcomes of ER for SNADETs in a large case series.METHODS This retrospective study included cases that underwent ER for SNADETs at our university hospital between March 2004 and July 2017. Short-term outcomes of ER were measured based on en bloc and R0 resection rates as well as adverse events. Long-term outcomes included local recurrence detected on endoscopic surveillance and disease-specific mortality in patients followed up for ≥ 12 mo after ER.RESULTS In the study, 131 patients with 147 SNADETs were analyzed. The 147 ERs consisted of 136 endoscopic mucosal resections(EMRs)(93%) and 11 endoscopic submucosal dissections(ESDs)(7%). The median tumor diameter was 10 mm.The pathology diagnosis was adenocarcinoma(56/147, 38%), high-grade intraepithelial neoplasia(44/147, 30%), or low-grade intraepithelial neoplasia(47/147, 32%). The R0 resection rate was 68%(93/136) in the EMR group and73%(8/11) in the ESD group, respectively. Cap-assisted EMR(known as EMR-C)showed a higher rate of R0 resection compared to the conventional method of EMR using a snare(78% vs 62%, P = 0.06). No adverse event was observed in the EMR group, whereas delayed bleeding, intraoperative perforation, and delayed perforation in 3, 3, and 5 patients occurred in the ESD group, respectively. One patient with perforation required emergency surgery. In the 43 mo median follow-up period, local recurrence was found in four EMR cases and all cases were treated endoscopically. No patient died due to tumor recurrence.CONCLUSION Our findings suggest that ER provides good long-term outcomes in the patients with SNADETs. EMR is likely to become the safe and reliable treatment for small SNADETs.

Diagnosis and management of ampullary adenoma:The expanding role of endoscopy

Ampullary adenoma is a pre-cancerous lesion arising from the duodenal papilla that is often asymptomatic.It is important to distinguish whether the adenoma is sporadic or arises in the setting of familial adenomatous polyposis as this has important implications with respect to management and surveillance.Multiple modalities are available for staging of these lesions to help guide the most appropriate therapy.Those that are used most commonly include computed tomography,endoscopic ultrasound,and endoscopic retrograde cholangiopancreatography.In recent years,endoscopy has become the primary modality for therapeutic management of the majority of ampullary adenomas.Surgery remains the standard curative procedure for confirmed or suspected adenocarcinoma.This review will provide the framework for the diagnosis and management of ampullary adenomas from the perspective of the practicing gastroenterologist.

Nonampullary duodenal adenoma:Current understandingof its diagnosis,pathogenesis,and clinical management

Nonampullary duodenal adenomas are relatively common in familial adenomatous polyposis(FAP), but nonampullary sporadic duodenal adenomas(SDAs)are rare. Emerging evidence shows that duodenal adenomas, regardless of their anatomic location and whether they are sporadic or FAP-related, share morphologic and molecular features with colorectal adenomas. The available data suggest that duodenal adenomas develop to duodenal adenocarcinomas via similar mechanisms. The optimal approach for management of duodenal adenomas remains to be determined. The techniques for endoscopic resection of duodenal adenoma include snare polypectomy, endoscopic mucosal resection(EMR), endoscopic submucosal dissection(ESD), and argon plasma coagulation ablation. EMR may facilitate removal of large duodenal polyps. Although several studies have reported cases of successful ESD for duodenal adenomas, the procedure is technically difficult to perform safely because of the anatomical properties of the duodenum. Although current clinical practice recommends endoscopic resection of all large duodenal adenomas in patients with FAP, endoscopic treatment is usually insufficient to guarantee a polypfree duodenum. Surgery is indicated for FAP patients with severe polyposis or nonampullary SDAs or FAPrelated polyps not amenable to endoscopic resection. Further studies are needed to develop newer endoscopic techniques to guide diagnostic and therapeutic decisions for future management of nonampullary duodenal adenomas.

Selection of appropriate endoscopic therapies for duodenal tumors: An open-label study, single-center experience

AIM: To determine an appropriate compartmentalization of endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) for duodenal tumors.

Pancreaticoduodenectomy for duodenal papilla carcinoma: A single-centre 9-year retrospective study of 112 patients with long-term follow-up

AIM To retrospectively evaluate the factors that influence long-term outcomes of duodenal papilla carcinoma (DPC) after standard pancreaticoduodenectomy (SPD). METHODS This is a single-centre, retrospective study including 112 DPC patients who had a SPD between 2006 and 2015. Associations between serum levels of CA19-9 and CEA and various clinical characteristics of 112 patients with DPC were evaluated by the. 2 test and Fisher's exact test. The patients were followed-up every 3 mo in the first two years and at least every 6 mo afterwards, with a median follow-up of 60 mo (ranging from 4 mo to 168 mo). Survival analysis was conducted using the Kaplan-Meier survival and Cox proportional hazards model analysis. The difference in survival curves was evaluated with a log-rank test. RESULTS In 112 patients undergoing SPD, serum levels of CA19-9 was associated with serum levels of CEA and drainage mode (the P values were 0.000 and 0.033, respectively); While serum levels of CEA was associated with serum levels of CA19-9 and differentiation of the tumour (the P values were 0.000 and 0.033, respectively). The serum levels of CA19-9 and CEA were closely correlated (chi(2) = 13.277, r = 0.344, P = 0.000). The overall 5-year survival was 50.00% for 112 patients undergoing SPD. The Kaplan-Meier survival analysis showed that increased serum levels of CA19-9, CEA, and total bilirubin were correlated with a poor prognosis, as well as a senior grade of infiltration depth, lymph node metastases, and TNM stage(the P values were 0.033, 0.018, 0.015, 0.000, 0.000 and 0.000, respectively). Only the senior grade of infiltration depth and TNM stage retained their significance when adjustments were made for other known prognostic factors in Cox multivariate analysis (RR = 2.211, P = 0.022 and RR = 2.109, P = 0.047). CONCLUSION For patients with DPC, the serum levels of CA19-9 and CEA were closely correlated, and play an important role in poor survival. Increased serum levels of total bilirubin and lymph node metastases were also correlated with a poor prognosis. The senior grade of infiltration depth and TNM stage can serve as independent prognosis indexes in the evaluation of patients with DPC after SPD.

Clinical outcomes of patients with duodenal adenocarcinoma and intestinal-type papilla of Vater adenocarcinoma

BACKGROUND Duodenal adenocarcinoma(DA)and intestinal-type papilla of Vater adenocarcinoma(it-PVA)are rare malignancies of the gastrointestinal tract.Current therapeutic options are translated nowadays from treatment strategies for patients with colorectal cancer due to histopathological similarities.AIM To retrospectively investigate the clinical outcome of patients with DA and it-PVA.METHODS All patients with DA and it-PVA diagnosed between 2000 and 2017 were included at two academic centers in the Netherlands.All patients with histopathologically-confirmed DA or it-PVA were eligible for inclusion.Clinical outcome was compared between DA and it-PVA per disease stage.In the subgroup of stage IV disease,survival after local treatment of oligometastases was compared with systemic therapy or supportive care.RESULTS In total,155 patients with DA and it-PVA were included.Patients with it-PVA more often presented with stage I disease,while DA was more often diagnosed at stage IV(P<0.001).Of all patients,79%were treated with curative intent.The median survival was 39 mo,and no difference in survival was found for patients with DA and it-PVA after stratification for disease stage.Seven(23%)of 31 patients with synchronous stage IV disease underwent resection of the primary tumor,combined with local treatment of oligometastases.Local treatment of metastases was associated with an overall survival of 37 mo,compared to 14 and 6 mo for systemic therapy and supportive care,respectively.CONCLUSION Survival of patients with DA and it-PVA is comparable per disease stage.These results suggest a potential benefit for local treatment strategies in selected patients with oligometastases,although additional prospective studies are needed.

Clinical outcomes of endoscopic resection of superficial nonampullary duodenal epithelial tumors: A 10-year retrospective, single-center study

BACKGROUND Although premalignant duodenal lesions such as adenomas are uncommon,the incidences of these lesions have increased in recent times,and thus,the demand for minimally invasive treatments such as endoscopic resection(ER)has also increased.However,ER in the duodenum is more challenging than ER in other locations of the gastrointestinal tract.AIM To evaluate the safety and efficacy of ER for superficial nonampullary duodenal epithelial tumors(SNADETs)METHODS We performed a retrospective observational study on 56 consecutive patients(58 lesions)diagnosed with SNADETs that underwent ER from January 2011 to December 2020 at Yeungnam University Hospital.Patient demographics,lesion characteristics,and procedural and technical data were collected,and clinical outcomes,including procedure-related complications,completeness of resection,and recurrence were analyzed.RESULTS Median patient age was 57 years[range,26–77,30(53.6%)men].Endoscopic mucosal resection(EMR)was performed on 57 lesions(98.3%)and snare polypectomy on one(1.7%).Lesions consisted of 52 adenomas with low-grade dysplasia(89.7%),3 adenomas with high-grade dysplasia(5.2%),and 3 intramucosal adenocarcinomas(5.2%).There were 16 cases of intraprocedural bleeding(27.6%)and 1 case of delayed bleeding(1.7%),and all these 17 cases were successfully managed endoscopically.No perforation or procedure-related death occurred.Larger lesion size was associated with an increased risk of EMR-related bleeding(P=0.033).During a median follow-up period of 23 mo(range 6–100 mo),no local recurrence occurred,despite the fact one-third of the patients(19 lesions,32.8%)underwent piecemeal resection and 3 patients(3 lesions,5.2%)that underwent en bloc resection had a pathologically determined positive lateral margin.No patient died from a primary duodenal neoplasm.CONCLUSION The majority of SNADETs can be safely and curatively resected by EMR,and thus,based on consideration of the high incidence of fatal complications attributable to ESD,we conclude EMR,including piecemeal resection,should be considered the treatment of first choice for SNADETs.

Endoscopic and biopsy diagnoses of superficial, nonampullary, duodenal adenocarcinomas

AIM: To investigate the accuracy of endoscopic or biopsy diagnoses of superficial nonampullary duodenal epithelial tumors(NADETs).METHODS:Clinicopathological data were reviewed for84 superficial NADETs from 74 patients who underwent surgery or endoscopic resection between September2002 and August 2014 at a single prefectural cancer center.Superficial NADETs were defined as lesions confined to the mucosa or submucosa.Demographic and clinicopathological data were retrieved from charts,endoscopic and pathologic reports.Endoscopic reports included endoscopic diagnosis,location,gross type,diameter,color,and presence or absence of biopsy.Endoscopic diagnoses were made by an endoscopist in charge of the examination before biopsy specimens were obtained.Endoscopic images were obtained using routine,front-view,high-resolution video endoscopy,and chromoendoscopy with indigocarmine was performed for all lesions.Endoscopic images were reviewed by at least two endoscopists to assess endoscopic findings indicative of carcinoma.Preoperative diagnoses based on endoscopy and biopsy findings were compared with histological diagnoses of resected specimens.Sensitivity,specificity,and accuracy were assessed for endoscopic diagnosis and biopsy diagnosis.RESULTS:The majority(81%)of the lesions were located in the second portion of the duodenum.The median lesion diameter was 14.5 mm according to final histology.Surgery was performed for 49 lesions from 39 patients,and 35 lesions from 35 patients were endoscopically resected.Final histology confirmed 65carcinomas,15 adenomas,and 3 hyperplasias.A finaldiagnosis of duodenal carcinoma was made for 91%(52/57)of the lesions diagnosed as carcinoma by endoscopy and 93%(42/45)of the lesions diagnosed as carcinoma by biopsy.The sensitivity,specificity,and accuracy of endoscopic diagnoses were 80%,72%,and 78%,respectively,whereas those of biopsy diagnoses were 72%,80%,and 74%,respectively.Preoperative diagnoses of carcinomas were made in88%(57/65)of the carcinoma lesions via endoscopy or biopsy.Endoscopic findings associated with carcinoma were red color,depression,and mixed-type morphology.CONCLUSION:Preoperative endoscopy and biopsy showed similar accuracies in the diagnosis of carcinoma in patients with superficial NADETs.

Future directions of duodenal endoscopic submucosal dissection

Endoscopic therapies for lesions of the duodenum are technically more difficult than those for lesions of the other parts of the gastrointestinal tract due to the anatomical features of the duodenum, and the incidence rate of complications such as perforation and bleeding is also higher. These aforementioned trends were especially noticeable for the case of duodenal endoscopic submucosal dissection(ESD). The indication for ESD of duodenal tumors should be determined by assessment of the histopathology, macroscopic morphology, and diameter of the tumors. The three types of candidate lesions for endoscopic therapy are adenoma, carcinoma, and neuroendocrine tumors. For applying endoscopic therapies to duodenal lesions, accurate preoperative histopathological diagnosis is necessary. The most important technical issue in duodenal ESD is the submucosal dissection process. In duodenal ESD, a short needle-type knife is suitable for the mucosal incision and submucosal dissection processes, and the Small-caliber-tip Transparent hood is an important tool. After endoscopic therapies, the wound should be closed by clipping in order to prevent complications such as secondary hemorrhage and delayed perforation. At present, the criteria for selection between ESD and EMR vary among institutions. The indications for ESD should be carefully considered. Duodenal ESD should have limitations, such as the need for its being performed by experts with abundant experience in performing the procedure.

Duodenal intussusception secondary to ampullary adenoma: A case report

BACKGROUND Because the duodenum is fixed onto the retroperitoneum, duodenal intussusception is usually impossible except in cases of malrotational abnormality. Although cases of duodenal intussusception without malrotational abnormalities have been reported, it is unclear whether they constitute true intussusception or simple mucosal prolapse. CASE SUMMARY A 66-year-old woman presented with whole-body edema and malaise. Blood analysis indicated severe anemia and cholestasis. Endoscopic examination revealed a pedunculate polyp on the second part of the duodenum that migrated distally with mucosal elongation. Computed tomography showed duodenal intussusception. A tumor as the lead point and retroperitoneal structure, including the head of the pancreas and fat, invaginated beyond the duodenojejunal flexure. She was diagnosed with ampullary adenoma caused repeated intussusception that reduced spontaneously and underwent pancreaticoduodenectomy. Laparotomy showed tumor prolapse beyond the duodenojejunal flexure without intussusception. There was no evidence of malrotational abnormality. She was discharged with no complications. CONCLUSION We report true duodenal intussusception without malrotational abnormality. This phenomenon was also associated with mucosal prolapse.

Application of endoscopic submucosal dissection in duodenal space-occupying lesions

BACKGROUNDEndoscopic submucosal dissection (ESD) has been advocated by digestiveendoscopists because of its comparable therapeutic effect to surgery, reducedtrauma, faster recovery, and fewer complications. However, ESD for lesions of theduodenum is more challenging than those occurring at other levels of thegastrointestinal tract due to the thin intestinal wall of the duodenum, narrowintestinal space, rich peripheral blood flow, proximity to vital organs, and highrisks of critical adverse events including intraoperative and delayed bleeding andperforation. Because of the low prevalence of the disease and the high risks ofsevere adverse events, successful ESD for lesions of the duodenum has rarelybeen reported in recent years.AIM To investigate the efficacy and safety of ESD in the treatment of duodenal spaceoccupyinglesions.METHODS Clinical data of 24 cases of duodenal lesions treated by ESD at the DigestiveEndoscopy Center of the Affiliated Hospital of Qingdao University from January2016 to December 2019 were retrospectively analyzed.RESULTS All of the 24 cases from 23 patients underwent ESD treatment for duodenal spaceoccupyinglesions under general anesthesia, including 15 male and 8 femalepatients, with a mean age of 58.5 (32.0-74.0) years. There were 12 lesions (50%) inthe duodenal bulb, 9 (37.5%) in the descending part, and 3 (12.5%) in the ball descending junction. The mean diameter of the lesion was 12.75 (range, 11-22)mm. Thirteen lesions originated from the mucosa, of which 4 were low-gradeintraepithelial neoplasia, 3 were hyperplastic polyps, 2 were chronic mucositis, 2were adenomatous hyperplasia, 1 was high-grade intraepithelial neoplasia, and 1was tubular adenoma. Eleven lesions were in the submucosa, including 5neuroendocrine neoplasms, 2 cases of ectopic pancreas, 1 stromal tumor, 1leiomyoma, 1 submucosal duodenal adenoma, and 1 case of submucosal lymphfollicular hyperplasia. The intraoperative perforation rate was 20.8% (5/24),including 4 submucosal protuberant lesions and 1 depressed lesion. The meanlength of hospital stay was 5.7 (range, 3-10) d, and the average follow-up time was25.8 (range, 3.0–50.0) mo. No residual disease or recurrence was found in allpatients, and no complications, such as infection and stenosis, were found duringthe follow-up period.CONCLUSION ESD is safe and effective in the treatment of duodenal lesions;however, theendoscopists should pay more attention to the preoperative preparation,intraoperative skills, and postoperative treatment.

Adult duodenal intussusception with horizontal adenoma: A rare case report

BACKGROUND Adult duodenal intussusception rarely occurs,and the majority of duodenal adenomas are located in the descending part of the duodenum.Therefore,adenomas in the horizontal part of the duodenum presenting as duodenal intussusception in adults are extremely rare.CASE SUMMARY A 36-year-old man complained of abdominal pain for 13 d.Blood analysis showed anemia.Magnetic resonance cholangiopancreatography and computed tomography revealed a tumor in the horizontal part of the duodenum as the main finding,leading to duodeno-duodenal intussusception.No obvious abnormalities were found on endoscopy or upper gastrointestinal radiography.He was diagnosed with duodenal intussusception secondary to duodenal adenoma.Laparotomy showed duodeno-duodenal intussusception and a tumor in the horizontal part of the duodenum near the ascending part.Postoperative pathology revealed tubular-villous adenoma with low-grade glandular intraepithelial neoplasia(local high-grade intraepithelial neoplasia).He was discharged without complications.CONCLUSION This case highlights that rational use of computed tomography,magnetic resonance cholangiopancreatography,endoscopy and upper gastrointestinal radiography for preoperative diagnosis and timely surgery is an effective strategy for the treatment of adult duodenal intussusception with duodenal masses.

Repeat full-thickness resection device use for recurrent duodenal adenoma: A case report

BACKGROUND Endoscopic full-thickness resection of adenomas or subepithelial tumors is a novel and promising endoscopic technique.There have been several recent studies of full-thickness resection device(FTRD)use in the colon,but data regarding its use and efficacy in the duodenum are still limited.CASE SUMMARY A 64-year-old female underwent resection of a recurrent adenoma of 7 mm in size in the duodenum after FTRD use for an adenoma eight months prior.The biopsies revealed a low-grade adenoma.The adenoma was removed using the gastroduodenal FTRD,and the pathology results revealed clear margins.Except for minor bleeding that was treated by argon plasma coagulation,no further complications occurred.CONCLUSION Repeat use of the FTRD appears to be a safe and efficacious approach for the treatment of recurrent duodenal lesions.Further prospective studies are needed to investigate the long-term safety and utility of repeat FTRD use after Endoscopic full-thickness resection.

内镜下十二指肠乳头腺瘤切除术后出血原因分析及列线图模型构建

目的分析并探讨内镜下十二指肠乳头腺瘤切除术后出血的原因,并构建列线图预测模型。方法回顾性分析2018年01月至2023年12月在我院行内镜下十二指肠乳头腺瘤切除术的患者共233例,根据术后是否发生出血分为出血组(n=31例)和未出血组(n=202例)。比较两组的临床资料,采用多因素logistic回归分析术后出血独立危险因素,并构建风险列线图预测模型,采用Bootstrap法重复抽样1000次展开内部验证。结果服用抗凝血药物(OR=9.063,95%CI:2.132~38.525)、病灶直径≥2 cm(OR=2.802,95%CI:1.073~7.321)、术中分片切除(OR=27.653,95%CI:3.055~619.174)、术后合并胰腺炎(OR=6.859,95%CI:1.930~24.377)是内镜下十二指肠乳头腺瘤切除术后出血的独立危险原因,(P<0.05)。根据Logistic回归分析结果构建风险预测列线图模型,通过Bootstrap法对样本重复抽样1000次开展内部验证,结果显示ROC曲线下的面积为0.850,95%CI为0.780~0.913,模型区分能力好。校准曲线显示列线图预测模型预测术后出血概率与实际术后出血概率具有较好的一致性,Hosmer-Lemeshow显示拟合优度良好(χ^(2)=3.3049,P=0.9138)。结论服用抗凝血药物、病灶直径≥2 cm、术中分片切除、术后合并胰腺炎是内镜下十二指肠乳头腺瘤切除术后出血独立危险因素,以此建立列线图预测模型,评估患者术后出血风险,为早期临床预防及干预提供决策依据。