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.

Drug-induced mucosal alterations observed during esophagogastroduodenoscopy

Several features of drug-induced mucosal alterations have been observed in the upper gastrointestinal tract,i.e.,the esophagus,stomach,and duodenum.These include pill-induced esophagitis,desquamative esophagitis,worsening of gastroesophageal reflux,chemotherapy-induced esophagitis,proton pump inhibitor-induced gastric mucosal changes,medication-induced gastric erosions and ulcers,pseudomelanosis of the stomach,olmesartan-related gastric mucosal inflammation,lanthanum deposition in the stomach,zinc acetate hydrate tabletinduced gastric ulcer,immune-related adverse event gastritis,olmesartan-associated sprue-like enteropathy,pseudomelanosis of the duodenum,and lanthanum deposition in the duodenum.For endoscopists,acquiring accurate knowledge regarding these diverse drug-induced mucosal alterations is crucial not only for the correct diagnosis of these lesions but also for differential diag-nosis of other conditions.This minireview aims to provide essential information on druginduced mucosal alterations observed on esophagogastroduodenoscopy,along with representative endoscopic images.

Effectiveness and safety of over-the-scope clip in closing perforations after duodenal surgery

BACKGROUND Endoscopic resection of duodenal subepithelial lesions(SELs)is a difficult procedure with a high risk of perforation.At present,dealing with perforation after endoscopic resection of duodenal SELs is still considered a great challenge.AIM To evaluate the effectiveness and safety of an over-the-scope clip(OTSC)in the treatment of perforation post-endoscopic resection of duodenal SELs.METHODS From May 2015 to November 2019,18 patients with perforation following endoscopic resection of duodenal SELs were treated with OTSCs.Data comprising the rate of complete resection,closure of intraprocedural perforation,delayed bleeding,delayed perforation,and postoperative infection were extracted.RESULTS The rate of complete removal of duodenal SELs and successful closure of the perforation was 100%.The median perforation size was 1 cm in diameter.Seventeen patients had minor intraoperative bleeding,while the remaining 1 patient had considerable amount of bleeding during the procedure.Seven patients had postoperative abdominal infections,of which 1 patient developed an abscess in the right iliac fossa and another patient developed septic shock.All 18 patients recovered and were discharged.No delayed bleeding or perforation was reported.The mean time taken to resume normal diet after the procedure was 6.5 d.The mean postoperative hospital stay was 9.5 d.No residual or recurrent lesions were detected during the follow-up period(15-66 mo).CONCLUSION Closing a perforation after endoscopic resection of duodenal SELs with OTSCs seems to be an effective and reasonably safe therapeutic method.

New hope for esophageal stricture prevention:A prospective singlecentertrial on acellular dermal matrix

BACKGROUNDGiven the high incidence of esophageal cancer in China,an increasing number ofpatients there are undergoing endoscopic mucosal dissection(ESD).Although the5-year survival rate after ESD can exceed 95%,esophageal stricture,the mostcommon and serious postoperative complication,affects the long-term prognosisof patients and the quality of life.Autologous mucosal grafts have proven to besuccessful in preventing stricture after ESD for early esophageal cancer.AIMTo examine the viability of acellular dermal matrix(ADM)as an alternative to autologous mucosa for the prevention of stricture after ESD.METHODSThis is a prospective,single-center,controlled study.Consecutive patients who underwent ESD surgery and werewilling to undergo autologous mucosal transplantation were recruited between January 1 and December 31,2017.Consecutive patients who underwent ESD surgery and were willing to undergo ADM transplantation wererecruited between January 1 to December 31,2019.A final three-year follow-up of patients who receivedtransplants was conducted.RESULTSBased on the current incidence of esophageal stricture,the sample size required for both the autologous mucosalgraft group and the ADM group was calculated to be 160 cases.Due to various factors,a total of 20 patients withautologous mucosal grafts and 25 with ADM grafts were recruited.Based on the inclusion exclusion andwithdrawal criteria,9 patients ultimately received autologous mucosal grafts and completed the follow-up,while11 patients received ADM grafts and completed the follow-up.Finally,there were 2 cases of stenosis in theautologous mucosal transplantation group with a stenosis rate of 22.22%and 2 cases of stenosis in the ADMtransplantation group with a stenosis rate of 18.18%,with no significant difference noted between the groups(P=0.94).CONCLUSIONIn this prospective,single-center,controlled trial,we compared the effectiveness of autologous mucosatransplantation and ADM for the prevention of esophageal stricture.Due to certain condition limitations,we wereunable to recruit sufficient subjects meeting our target requirements.However,we implemented strict inclusion,exclusion,and withdrawal criteria and successfully completed three years of follow-up,resulting in valuableclinical insights.Based on our findings,we hypothesize that ADM may be similarly effective to autologousmucosal transplantation in the prevention of esophageal stricture,offering a comparable and alternative approach.This study provides a new therapeutic idea and direction for the prevention of esophageal stricture.