Endoscopic mucosal resection vs endoscopic submucosal dissection for superficial non-ampullary duodenal tumors

BACKGROUND The selection of endoscopic treatments for superficial non-ampullary duodenal epithelial tumors(SNADETs)is controversial.AIM To compare the efficacy and safety of endoscopic mucosal resection(EMR)and endoscopic submucosal dissection(ESD)for SNADETs.METHODS We retrospectively analyzed the data of patients with SNADETs from a database of endoscopic treatment for SNADETs,which included eight hospitals in Fukuoka,Japan,between April 2001 and October 2017.A total of 142 patients with SNADETs treated with EMR or ESD were analyzed.Propensity score matching was performed to adjust for the differences in the patient characteristics between the two groups.We analyzed the treatment outcomes,including the rates of en bloc/complete resection,procedure time,adverse event rate,hospital stay,and local or metastatic recurrence.RESULTS Twenty-eight pairs of patients were created.The characteristics of patients between the two groups were similar after matching.The EMR group had a significantly shorter procedure time and hospital stay than those of the ESD group[median procedure time(interquartile range):6(3-10.75)min vs 87.5(68.5-136.5)min,P<0.001,hospital stay:8(6-10.75)d vs 11(8.25-14.75)d,P=0.006].Other outcomes were not significantly different between the two groups(en bloc resection rate:82.1%vs 92.9%,P=0.42;complete resection rate:71.4%vs 89.3%,P=0.18;and adverse event rate:3.6%vs 17.9%,P=0.19,local recurrence rate:3.6%vs 0%,P=1;metastatic recurrence rate:0%in both).Only one patient in the ESD group underwent emergency surgery owing to intraoperative perforation.CONCLUSION EMR has significantly shorter procedure time and hospital stay than ESD,and provides acceptable curability and safety compared to ESD.Accordingly,EMR for SNADETs is associated with lower medical costs.

Endoscopic diagnosis and treatment of superficial nonampullary duodenal tumors

The diagnostic and treatment guidelines of superficial non-ampullary duodenal tumors have not been standardized due to their low prevalence.Previous reports suggested that a superficial adenocarcinoma(SAC) should be treated via local resection because of its low risk of lymph node metastasis,whereas a highgrade adenoma(HGA) should be resected because of its high risk of progression to adenocarcinoma.Therefore,pretreatment diagnosis of SAC or HGA is important to determine the appropriate treatment strategy.There are certain endoscopic features known to be associated with SAC or HGA,and current practice prioritizes the endoscopic and biopsy diagnosis of these conditions.Surgical treatment of these duodenal lesions is often related to high risk of morbidity,and therefore endoscopic resection has become increasingly common in recent years.Endoscopic mucosal resection(EMR) and endoscopic submucosal dissection(ESD) are the commonly performed endoscopic resection methods.EMR is preferred due to its lower risk of adverse events;however,it has a higher risk of recurrence than ESD.Recently,a new and safer endoscopic procedure that reduces adverse events from EMR or ESD has been reported.

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.

Laparoscopic and endoscopic co-operative surgery for nonampullary duodenal tumors

AIM To assess the safety and feasibility of laparoscopic and endoscopic co-operative surgery(LECS) for early nonampullary duodenal tumors.METHODS Twelve patients with a non-ampullary duodenal tumor underwent LECS at our hospital. One patient had two mucosal lesions in the duodenum. The indication for this procedure was the presence of duodenal tumors with a low risk for lymph node metastasis. In particular, the tumors included small(less than 10 mm) submucosal tumors(SMT) and epithelial mucosal tumors, such as mucosal cancers or large mucosal adenomas with malignant suspicion. The LECS procedures, such as full-thickness dissection for SMT and laparoscopic reinforcement after endoscopic submucosal dissection(ESD) for epithelial tumors, were performed for the 13 early duodenal lesions in 12 patients. Here we present the short-term outcomes and evaluate the safety and feasibility of this new technique.RESULTS Two SMT-like lesions and eleven superficial epithelial tumor-like lesions were observed. Seven and Six lesions were located in the second and third parts of the duodenum, respectively. All lesions were successfully resected en bloc. The defect in the duodenal wall was manually sutured after resection of the duodenal SMT. For epithelial duodenal tumors, the ulcer bed was laparoscopically reinforced via manual suturing after ESD. Intraoperative perforation occurred in two out of eleven epithelial tumor-like lesions during ESD; however, they were successfully laparoscopically repaired. The median operative time and intraoperative estimated blood loss were 322 min and 0 mL, respectively. Histological examination of the tumors revealed one adenoma with moderate atypia, ten adenocarcinomas, and two neuroendocrine tumors. No severe postoperative complications(Clavien-Dindo classification grade Ⅲ or higher) were reported in this series, but minor leakage secondary to pancreatic fistula occurred in one patient.CONCLUSION LECS can be a safe and minimally invasive treatment option for non-ampullary early duodenal tumors.

非壶腹部十二指肠浅表肿瘤内镜微创治疗的进展

近年来,随着内镜技术的不断发展,非壶腹部十二指肠浅表肿瘤(SNADET)病变的发现率逐渐增高,早期发现的SNADET较少进行远处转移,因此,诊断和治疗早期SNADET十分重要。该文通过对中外文献的查阅,分析汇总了SNADET内镜切除技术,以期为如何改善SNADET的内镜微创治疗,提高其疗效及安全性,提高患者的生活质量,对进一步深入研究提供思路与帮助。