Sporadic duodenal adenoma is associated with colorectal neoplasia

Treatment for superficial non-ampullary duodenal epithelial tumors

Because of the low prevalence of non-ampullary duodenal epithelial tumors (NADETs), standardized clinical management of sporadic superficial NADETs, including diagnosis, treatment, and follow-up, has not yet been established. Retrospective studies have revealed certain endoscopic findings suggestive of malignancy. Duodenal adenoma with high-grade dysplasia and mucosal cancer are candidates for local resection by endoscopic or minimally invasive surgery. The use of endoscopic treatment including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), for the treatment for superficial NADETs is increasing. EMR requires multiple sessions to achieve complete remission and repetitive endoscopy is needed after resection. ESD provides an excellent complete resection rate, however it remains a challenging method, considering the high risk of intraoperative or delayed perforation. Minimally invasive surgery such as wedge resection and pancreas-sparing duodenectomy are beneficial for superficial NADETs that are technically difficult to remove by endoscopic treatment. Pancreaticoduodenectomy remains a standard surgical procedure for treatment of duodenal cancer with submucosal invasion, which presents a risk of lymph node metastasis. Endoscopic or surgical treatment outcomes of superficial NADETs without submucosal invasion are satisfactory. Establishing an endoscopic diagnostic tool to differentiate superficial NADETs between adenoma and cancer as well as between mucosal and submucosal cancer is required to select the most appropriate treatment.

Duodenal adenomas coincide with colorectal neoplasia

BACKGROUND AND AIM

Small case series have alluded to an association between sporadic duodenal adenomas and colorectal neoplasia. The strength of the association remains uncertain. This case-control study was designed to test this association in a large national pathology database.

METHODS

This study, performed at Miraca Life Sciences, a specialized pathology laboratory that receives gastrointestinal biopsy specimens from outpatient centers throughout the US, included all subjects who underwent a bidirectional endoscopy with biopsy results from both procedures between January 2008 and December 2011. The association between duodenal and colonic neoplasms was investigated using odds ratios (OR) and their 95 % confidence intervals (CIs) derived from univariate and multivariate analyses.

RESULTS

There were 203,277 patients who underwent bidirectional procedures within the study period (mean age 58 years, 58 % females). Duodenal adenomas were present in 537 patients (median age 65 years, 51 % females; OR for male sex 1.34, 95 % CI 1.13-1.59). Hyperplastic colon polyps were present in 30,205 and colon adenomas in 85,801 patients. Hyperplastic polyps were more common in patients with duodenal adenomas (1.45, 1.07-1.95). Patients with duodenal adenomas also had a significantly greater prevalence of all types of colonic adenomas (2.65, 2.16-3.25), particularly of advanced adenomas (4.30, 3.24-5.70) and colorectal cancer (3.13, 1.38-7.12). Duodenal adenomas were associated with an equally increased risk for left and right colon adenomas.

CONCLUSIONS

Patients with duodenal adenomas harbor an increased risk for any type of colonic neoplasm. This association may provide new insights into the general mechanisms underlying mucosal proliferation in the gastrointestinal tract.

CpG island methylator phenotype and its association with malignancy in sporadic duodenal adenomas

CpG island methylator phenotype (CIMP) has been found in multiple precancerous and cancerous lesions, including colorectal adenomas, colorectal cancers, and duodenal adenocarcinomas. There are no reports in the literature of a relationship between CIMP status and clinicopathologic features of sporadic duodenal adenomas. This study sought to elucidate the role of methylation in duodenal adenomas and correlate it with KRAS and BRAF mutations. CIMP+ (with more than 2 markers methylated) was seen in 33.3% of duodenal adenomas; 61% of these CIMP+ adenomas were CIMP-high (with more than 3 markers methylated). Furthermore, CIMP+ status significantly correlated with older age of patients, larger size and villous type of tumor, coexistent dysplasia and periampullary location. MLH1 methylation was seen in 11.1% of duodenal adenomas and was significantly associated with CIMP+ tumors, while p16 methylation was an infrequent event. KRAS mutations were frequent and seen in 26.3% of adenomas; however, no BRAF mutations were detected. Furthermore, CIMP-high status was associated with larger size and villous type of tumor and race (non-white). These results suggest that CIMP+ duodenal adenomas may have a higher risk for developing malignancy and may require more aggressive management and surveillance.

Endoscopic resection of large sporadic non-ampullary duodenal polyps: efficacy and long-term recurrence

BACKGROUND

Endoscopic resection is an alternative to surgery for removal of large duodenal polyps. There are limited data on the safety, efficacy, and long-term recurrence data after endoscopic resection of sporadic, non-ampullary, and large duodenal polyps.

OBJECTIVE

Our aim was to evaluate the safety and short-term outcomes of the endoscopic removal of the large sporadic duodenal polyps and to determine long-term risk of recurrence and factors predicting recurrence on follow-up.

METHODS

Patients with large (>10 mm) sporadic non-ampullary duodenal polyps underwent endoscopic resection from 2001 to 2012 at the Cleveland Clinic. Patients underwent endoscopic polypectomy and argon plasma coagulation. The main outcome measurements were complete polypectomy, complications, short- and long-term recurrence.

RESULTS

A total of 54 patients were included. The mean patient age was 66.4 years. The mean polyp size was 15.1 ± 5.4 mm. Most polyps (N = 48, 88.9 %) were sessile polyps. The median follow-up time was 10.8 (range 0.5-120) months. Most lesions were located in the second part of the duodenum (N = 41, 75.9 %). Adenomas were found in 46 (85.2 %) of lesions overall. Tubular adenoma was the most common histology type found in 33 cases (71.7 %). Tubulovillous and villous were found in 12 (26.1 %) and 1 (2.2 %) cases, respectively. On follow-up, 50 (92.6 %) achieved complete resection with tumor free margins post resection. The 30-day risk of major complications was 5.6 % (N = 3), 1 with perforation and 2 with delayed bleeding. Recurrence was documented in 29 % (N = 16) of patients. All recurrences were managed endoscopically except for one patient who required surgery. The recurrence rate was higher for patients who had villous component in their adenomas compared to those with tubular alone (p = 0.03).

CONCLUSIONS

Endoscopic resection is effective for treating large duodenal adenomas. Adenomas with villous features are more likely to recur. Almost all recurrences can be managed endoscopically.

Clinical significance of colonoscopy in patients with upper gastrointestinal polyps and neoplasms: a meta-analysis

BACKGROUND

Some authors have studied the relationship between the presence of polyps, adenomas and cancers of upper gastrointestinal tract (stomach and duodenum) and risk of colorectal polyps and neoplasms; however, the results are controversial, which may be due to study sample size, populations, design, clinical features, and so on. No meta-analysis, which can be generalized to a larger population and could provide a quantitative pooled risk estimate of the relationship, of this issue existed so far.

METHODS

We performed a meta-analysis to evaluate risk of colorectal polyps or neoplasms in patients with polyps, adenomas or cancers in upper gastrointestinal tract comparing with controls. A search was conducted through PubMed, EMBASE, reference lists of potentially relevant papers, and practice guidelines up to 27 November 2013 without languages restriction. Odd ratios (ORs) were pooled using random-effects models.

RESULTS

The search yielded 3 prospective and 21 retrospective case-control studies (n = 37152 participants). The principal findings included: (1) OR for colorectal polyps was 1.15 (95% CI, 1.04-1.26) in the gastric polyps group comparing with control groups; (2) Patients with gastric polyps and neoplasms have higher risk (OR, 1.31 [95% CI, 1.06-1.62], and 1.72 [95% CI, 1.42-2.09], respectively) of colorectal neoplasms comparing with their controls; and (3) Positive association was found between the presence of colorectal neoplasms and sporadic duodenal neoplasms (OR, 2.59; 95% CI, 1.64-4.11).

CONCLUSIONS

Findings from present meta-analysis of 24 case-control studies suggest that the prevalence of colorectal polyps was higher in patients with gastric polyps than in those without gastric polyps, and the risk of colorectal neoplasms increases significantly in patients with gastric polyps, neoplasms, and duodenal neoplasms. Therefore, screening colonoscopy should be considered for patients with upper gastrointestinal polyps and neoplasms.

Advanced precancerous lesions in the small bowel mucosa

The small intestine has comparatively low rates of epithelial cancers and is, for the most part, inaccessible to ordinary endoscopic visualization. As a result, few solid data are available on the pathological, clinical, and therapeutic aspects of epithelial dysplasia in the small intestine. In this review, we discuss the duodenal adenoma, the most readily visualized dysplastic lesion of the small intestine and the only one that can be detected in an early phase and resected endoscopically before it progresses to high-grade or invasive carcinoma. Particular emphasis is placed on the relationship between duodenal adenoma and colon neoplasia. Because of their different behaviour, detection and management of ampullary adenomas is discussed separately. Even if the absolute risk remains small, the incidence of adenocarcinoma in the small bowel is increased 32-fold in patients with ileal Crohn's disease. Therefore, the follow up and management of these patients is discussed with particular emphasis on the occurrence of dysplasia in the small bowel mucosa of the post-restorative proctocolectomy patients.

Multiple adenomatous duodenal polyposis

Multiple duodenal polyps are a relatively rare finding, usually co-occurrent with familial adenomatous polyposis (FAP).We report a patient with multiple duodenal adenomas and a negative examination for FAP: multiple flat polyps were detected endoscopically in a 37-year-old male patient, extending from the apex of the bulb to the end of the descending part of the duodenum. In terms of histology, they were tubular adenomas with moderate dysplasia. Colonoscopy and enteroclysis were normal. Both push and capsule enteroscopy only showed multiple polyps in the area of the descending duodenum. DNA analysis of the APC gene was as follows: DGGE, exon 1-15, deletion at codons 1309 and 1061 by means of PCR for attenuated APC were negative. Afterwards we screened the patient for germline MYH mutations using the denaturing high-performance liquid chromatography (DHPLC) in combination with sequencing. No novel pathogenic mutation has been identified. Large polyps were removed by means of endoscopic polypectomy and mucosectomy, while small polyps were removed by means of argon plasma coagulation.We conduct yearly checkups, removing only sporadic polyps. The rare finding of duodenal polyposis not co-occurrent with FAP proves that multiple adenomas in the digestive tube need not necessarily co-occur with FAP.

Management of sporadic duodenal adenomas and the association with colorectal neoplasms: a retrospective cohort study

GOALS

To evaluate management, outcome, and follow-up of patients with sporadic duodenal adenomas and assess the presence of colorectal neoplasms.

BACKGROUND

With the widespread use of esophagogastroduodenoscopy, an increasing number of sporadic duodenal adenomas are diagnosed. An optimal algorithm for management has not been fully defined. Accumulating data suggest an association with colorectal neoplasms.

STUDY

Patients diagnosed with sporadic duodenal adenomas at our institute from 1986 until 2008 were retrospectively reviewed. Data were collected from medical records.

RESULTS

Fifty-four patients (28 men, 52%) were diagnosed with a sporadic duodenal adenoma at a median age of 59 years (range, 27 to 84 y); 33 patients (61%) underwent endoscopic or surgical intervention, 5 (9%) were only followed endoscopically, and 16 (30%) underwent no intervention or follow-up. Complete endoscopic removal was accomplished in at least 81% of cases, and no complications were reported; surgical intervention was complicated in 4 patients, with 1 resulting in death. Adenoma recurrence was 20% at a median follow-up of 18 months (range, 4 to 54 mo), but no carcinoma developed. Colorectal neoplasms were found in 16 of 29 patients (55%) who underwent colonoscopy, including 2 cancers (7%), 7 advanced adenomas (24%), and 7 nonadvanced adenomas (24%).

CONCLUSIONS

Although no consistent approach to management of sporadic duodenal adenomas was followed, no duodenal carcinoma developed during the follow-up. Endoscopic intervention is preferred over surgical intervention, whenever possible. Once complete removal is ascertained, there is no strict indication for regular follow-up esophagogastroduodenoscopy, especially in elderly patients or patients with relevant comorbidity. Colonoscopic assessment is warranted in all patients diagnosed with sporadic duodenal adenomas.

Giant laterally spreading tumors of the duodenum: endoscopic resection outcomes, limitations, and caveats

BACKGROUND

Giant hemicircumferential and greater nonampullary duodenal adenomas or laterally spreading tumors (LSTs) may be amenable to safe endoscopic resection, but little data exists on outcomes or risk stratification.

DESIGN

We interrogated a prospectively maintained database of all patients who underwent endoscopic resection between January 2008 and November 2010. The resection technique was standardized. Major complications were defined as perforation, bleeding requiring readmission with hemoglobin drop of more than 20 g/L, or other substantial deviations from the usual clinical course. Outcomes were analyzed in 2 groups: giant lesions (>30 mm) and conventional duodenal polyps (<30 mm in diameter). Statistical evaluation was performed by using a χ(2) test.

RESULTS

A total of 50 nonampullary duodenal polyps and LSTs were resected from 46 patients (23 men, mean age 59.4 years, range 35-83 years). Nineteen were giant hemicircumferential and greater LSTs (mean size 40.5 mm, range 30-80 mm), and 31 were less than 30 mm in diameter (mean size 14.5 mm, range 5-25 mm). Intraprocedural bleeding occurred more frequently in giant lesions (57.8% vs 19.3%, P = .005) and was treated with a combination of soft coagulation and endoscopic clips with hemostasis achieved in all cases. Major complications, mostly bleeding related, occurred in 5 patients (26.3%) with giant lesions and 1 patient (3.2%) with a smaller lesion (P = .014). There were no deaths.

LIMITATION

Retrospective observational study in a tertiary center.

CONCLUSIONS

Endoscopic resection of giant nonampullary duodenal LSTs is a successful treatment. However, it is hazardous and associated with significantly higher complication rates, primarily bleeding, when compared with conventional duodenal polypectomy. Safer and more effective hemostatic tools are required in this high-risk location.

Endoscopic management of nonampullary duodenal polyps

Duodenal polyps are a rare finding in patients presenting for gastroscopy, being found in 0.3-4.6% of cases. The majority of patients are asymptomatic. The most common lesions necessitating removal are duodenal adenomas which should be differentiated from other mucosal lesions such as ectopic gastric mucosa, and submucosal lesions such as carcinoids and gastrointestinal stromal tumours (GISTs). Adenomas can occur sporadically or as part of a polyposis syndrome. Both groups carry malignant potential but this is higher in patients with a polyposis syndrome. The majority of sporadic duodenal adenomas are flat or sessile and occur in the second part of the duodenum. Historically duodenal adenomas have been managed by radical surgery, which carried significant mortality and morbidity, or more conservative local surgical excision which resulted in high local recurrence rates. There is growing evidence for the use of endoscopic mucosal resection (EMR) techniques for treatment of sporadic nonampullary duodenal adenomas, with good outcomes and low complication rates. Endoscopic submucosal dissection (ESD) carries greater risk of complications and should be reserved for experts in this technique. Patients with sporadic duodenal adenomas carry an increased risk of colonic neoplasia and should be offered colonoscopy. The impact of endoscopic resection on the course of polyposis syndromes such as familial adenomatous polyposis (FAP) needs further study.

Increased prevalence of colorectal neoplasia in korean patients with sporadic duodenal adenomas: a case-control study

BACKGROUND/AIMS

Recent data from Western populations have suggested that patients with sporadic duodenal adenomas are at a higher risk for the development of colorectal neoplasia. In this study, we compared the frequency of colorectal neoplasia in patients with sporadic duodenal adenomas to healthy control subjects.

METHODS

This retrospective case-control study used the databases of 3 teaching hospitals in Gyeonggi-do Province, South Korea. The colonoscopy findings of patients with sporadic duodenal adenomas were compared with those of age- and gender-matched healthy individuals who had undergone gastroduodenoscopies and colonoscopies during general screening examinations.

RESULTS

Between 2001 and 2008, 45 patients were diagnosed endoscopically with sporadic duodenal adenomas; 26 (58%) of these patients received colonoscopies. Colorectal neoplasia (42% vs 21%; odds ratio [OR], 2.8; 95% confidence interval [CI], 1.1 to 7.4) and advanced colorectal adenoma (19% vs 3%; OR, 9.0; 95% CI, 1.6 to 50.0) were significantly more common in patients with sporadic duodenal adenomas than in healthy control subjects.

CONCLUSIONS

Compared with healthy individuals, patients with sporadic duodenal adenomas were at a significantly higher risk for developing colorectal neoplasia. Such at-risk patients should undergo routine screening colonoscopies.

Sporadic nonampullary duodenal adenoma in the natural history of duodenal cancer: a study of follow-up surveillance

OBJECTIVES

Although sporadic nonampullary duodenal adenoma (SNDA) is regarded as a precancerous lesion, its natural course is uncertain. The aim of this study was to evaluate the risk of development of adenocarcinoma in SNDA lesions initially diagnosed as showing low-grade dysplasia (LGD; category 3) or high-grade dysplasia (HGD; category 4.1).

METHODS

We analyzed 68 SNDAs, diagnosed based on initial and subsequent biopsies, in 66 consecutive patients. Of these, 46 (43 LGD lesions, 3 HGD lesions) were followed up for ≥6 months without treatment (mean 27.7±16.9 months; range 6-72 months), including 8 lesions that were eventually resected during follow-up. Sixteen lesions (eight LGD lesions, eight HGD lesions) were resected immediately, either endoscopically or surgically, and six lesions were excluded because of a short follow-up (<6 months). The histopathological diagnoses and macroscopic changes were evaluated.

RESULTS

Among the 43 LGD lesions followed up for ≥6 months, 34 (79.1%) showed no histopathological changes during follow-up, whereas the remaining 9 (20.9%) showed progression to HGD, including 2 (4.7%) that progressed eventually to noninvasive carcinoma (category 4.2). Macroscopically, 76.7% (33 of 43) of the LGD lesions showed no notable changes in size, 16.3% (7 of 43) became undetectable, 4.7% (2 of 43) reduced in size, and 2.3% (1 of 43) became larger in size. In contrast, all the three HGD lesions that were followed up for ≥6 months remained unchanged histologically, based on biopsy, and showed no notable macroscopic changes, although one of these HGD lesions resected endoscopically revealed evidence of noninvasive carcinoma. Although we diagnosed all lesions as HGD from biopsy samples, a high percentage of cancers (54.5%, 6 of 11) were diagnosed from resected specimens. A multivariate analysis identified HGD diagnosed at first biopsy and a lesion diameter of ≥20 mm as being significantly predictive of progression to adenocarcinoma.

CONCLUSIONS

LGD lesions show a low risk of progression to adenocarcinoma, but some risk of progression to HGD, which warrants careful follow-up biopsy. However, HGD lesions and large SNDAs≥20 mm in diameter show a high risk of progression to adenocarcinoma. Therefore, they should be treated immediately.

Duodenal carcinoma at the ligament of Treitz. A molecular and clinical perspective

BACKGROUND

There is very small occurrence of adenocarcinoma in the small bowel. We present a case of primary duodenal adenocarcinoma and discuss the findings of the case diagnostic modalities, current knowledge on the molecular biology behind small bowel neoplasms and treatment options.

CASE

The patient had a history of iron deficiency anemia and occult bleeding with extensive workup consisting of upper endoscopy, colonoscopy, capsule endoscopy, upper gastrointestinal series with small bowel follow through and push enteroscopy. Due to persistent abdominal pain and iron deficiency anemia the patient underwent push enteroscopy which revealed adenocarcinoma of the duodenum. The patient underwent en-bloc duodenectomy which revealed T3N1M0 adenocarcinoma of the 4th portion of the duodenum.

CONCLUSIONS

Primary duodenal carcinoma, although rare should be considered in the differential diagnosis of occult gastrointestinal bleeding when evaluation of the lower and upper GI tract is unremarkable. We discuss the current evaluation and management of this small bowel neoplasm.

Do we need colonoscopy in patients with gastric adenomas? The risk of colorectal adenoma in patients with gastric adenomas

BACKGROUND

Gastric polyps are found frequently in various colonic polyposis syndromes. Genetic alterations of several genes occur in gastric adenomas and colorectal adenomas. However, it is unknown whether patients with gastric adenomas are at higher risk for colorectal adenomas.

OBJECTIVE

To investigate the prevalence rate of colorectal adenoma in patients with gastric adenomas and to determine the association between the presence of gastric adenomas and synchronous colorectal adenomas.

DESIGN

A retrospective, cross-sectional, case-control study.

SETTING

Single center: Center for Health Promotion of Samsung Medical Center.

PATIENTS

This study involved 87 patients with gastric adenomas and 174 sex-matched and age-matched controls among 19,019 participants who underwent EGD and colonoscopy simultaneously or within 6 months of each other from January 2001 to December 2008 at the Center for Health Promotion of Samsung Medical Center.

INTERVENTION

EGD and colonoscopy.

MAIN OUTCOME MEASUREMENTS

The prevalence rate of colorectal adenoma in patients with gastric adenomas.

RESULTS

The 87 gastric adenoma patients included 72 men and 15 women. Colorectal adenomas were identified in 42 (48.3%) of 87 cases and in 58 (33.3%) of 174 controls (P = .022). The prevalence of colorectal adenoma was significantly higher in the gastric adenoma group than in the control group. The mean size and number of colorectal adenomas were not significantly different between the two groups. The majority of colorectal adenomas were located in distal colonic segments in the gastric adenoma group in contrast with proximal colonic segments in the control group. Multivariate logistic regression analysis revealed that independent risk factors for colorectal adenoma were the presence of gastric adenomas (odds ratio [OR], .915; 95% confidence interval [CI], 1.044-3.513) and increasing age over 55 years (OR, 2.943; 95% CI, 1.558-5.560).

LIMITATIONS

Lack of data on previous colorectal adenomas and possible confounding factors such as hyperlipidemia or diabetes mellitus.

CONCLUSION

The risk of colorectal adenoma increases significantly in patients with gastric adenomas and in patients over age 55. A screening colonoscopy may be necessary for patients with gastric adenomas to detect colorectal adenomas.

Nonampullary duodenal polyps: characteristics and endoscopic management

BACKGROUND

Guidelines for endoscopic resection and surveillance of nonampullary duodenal (NAD) polyps are still not well-defined.

OBJECTIVE

To describe the characteristics of NAD polyps and evaluate the role of endoscopic management.

DESIGN

Retrospective review.

SETTING

Tertiary-care academic center.

PATIENTS

This study involved 59 patients with NAD polyps.

INTERVENTION

Endoscopic polypectomy, biopsy, and argon plasma coagulation.

MAIN OUTCOME MEASUREMENTS

Complete polypectomy, complications, and recurrence.

RESULTS

Ninety-six endoscopies were performed. The mean patient age was 62.8 years. The mean (+/- standard deviation) polyp size was 17.2 mm +/- 1.6 mm. The mean follow-up time was 26 months. Most lesions were sessile, solitary, and located in the descending duodenum. The procedure most often performed was submucosal injection followed by snare polypectomy. Adenomas were found in 68% of lesions overall and in 84% of lesions >2 cm. Successful resection was accomplished in 93% of cases on the initial attempt. Multiple endoscopies were needed in 5% of cases. The overall complete resection rate was 98%. Recurrence was documented in 37% of cases. Complications occurred in 5.2% of patients. Polyps of >2 cm were associated with higher rates of adenoma and a higher incidence of recurrence. Colon adenomas were found in 53% of patients with duodenal adenomas.

LIMITATIONS

Retrospective review. Not all patients underwent colonoscopy.

CONCLUSION

NAD polyps were large, sessile, and more commonly found in the second portion of the duodenum. They are more likely to be adenomatous when the lesion size is >2 cm. Despite successful endoscopic management, over one third of lesions demonstrated recurrence.

Increased prevalance of colorectal adenoma in patients with sporadic duodenal adenoma

OBJECTIVES

Duodenal adenomas are common in familial adenomatous polyposis (FAP). It is, however, not known whether patients with duodenal adenomas without FAP should undergo routine colonoscopy for detection of colorectal neoplasia. The aim of this study was to evaluate the correlation between the incidence of sporadic duodenal adenomas and colorectal neoplasias.

METHODS

Patients with sporadic duodenal adenomas and without FAP were retrospectively evaluated for the existence of colorectal neoplasia. Each patient was compared with three randomly selected age and sex-matched controls.

RESULTS

Sporadic duodenal adenomas were diagnosed by endoscopy in 51 patients, of whom 48 underwent additional colonoscopy. The mean age of the 48 analysed patients was 66 (40-83) years (women:men=23 : 25). Colorectal neoplasia was significantly more common among patients with duodenal adenomas (75% vs. 27.7%; P<0.05; odds ratio=7.80 [95% confidence interval 3.48-17.72]).

CONCLUSION

In this case control study, the prevalence of colorectal adenomas in patients with sporadic duodenal adenomas without FAP was significantly increased compared with the average population. Therefore, patients with duodenal adenomas should be screened for the occurrence of colorectal adenomas.

EMR of large, sessile, sporadic nonampullary duodenal adenomas: technical aspects and long-term outcome (with videos)

BACKGROUND

EMR is a viable alternative to surgery for removal of large mucosal neoplastic lesions of the entire GI tract. Few studies have, however, been published on the safety, efficacy, and technical aspects of EMR in the duodenum.

OBJECTIVE

Our purpose was to evaluate the efficacy and safety of EMR of large (>15 mm) duodenal adenomas.

DESIGN

Retrospective evaluation of a defined patient cohort.

SETTING

Tertiary academic referral center.

PATIENTS

Patients with large (>15 mm) sporadic nonampullary duodenal adenomas managed by a standardized technique who were referred by other specialist endoscopists for endoscopic treatment.

METHODS

Five-year data from patients undergoing EMR for large duodenal adenomas were reviewed retrospectively. Immediate and delayed complications were recorded.

RESULTS

Twenty-one lesions were removed by EMR in 23 patients (mean age 62.2 years, 13 female, 10 male). The mean size of lesions resected was 27.6 mm (median 20 mm, range 15-60 mm). Post-EMR histologic examination revealed mucosal adenocarcinoma in 1, low-grade tubulovillous adenoma (TVA) in 16, high- or focal high-grade TVA in 3 patients, and 1 with both high-grade TVA and carcinoid. EMR was performed successfully in 18 patients during a single session. Two patients required 2 sessions and 1 required 3 sessions for complete resection. The median follow-up was 13 months (range 4-44 months). During follow-up, 5 patients had minor residual adenomas that were treated successfully with snare resection and/or argon plasma coagulation. One patient had EMR site bleeding. There were no perforations.

LIMITATION

Retrospective study.

CONCLUSION

EMR for large sporadic nonampullary duodenal adenomas is a safe and effective technique.

Sporadic duodenal adenoma and the association with colorectal neoplasia: a case-control study

OBJECTIVES

Sporadic duodenal adenomas are an uncommon finding. It is not clear whether patients with sporadic duodenal adenoma have a greater risk for colorectal neoplasia and should undergo colonoscopy. The aims of the present study were to estimate the prevalence of colorectal neoplasia in patients with sporadic duodenal adenoma, and to compare colorectal neoplasia rates in patients with sporadic duodenal adenomas versus those without them.

METHODS

A retrospective case-control study was conducted to identify sporadic duodenal adenoma patients using the databases of two academic and one regional hospital in the Netherlands. Colonoscopic findings in the sporadic duodenal adenoma patients were compared with those of a control group of patients who underwent both gastroduodenoscopy and colonoscopy. Furthermore, the frequency of colorectal cancer in the sporadic duodenal adenoma patients was compared with the population incidence of colorectal cancer.

RESULTS

During the period 1991-2006, 102 patients in total with sporadic duodenal adenomas were identified. Colonoscopy was performed in 49 patients (48%), and colorectal neoplasia was present in 21 of these patients (43%). There was a significantly higher rate of both colorectal neoplasia (43%vs 17%, odds ratio [OR] 3.6, 95% confidence interval [CI] 1.7-7.4) and advanced colorectal adenoma (18%vs 3%, OR 7.8, 95% CI 2.1-29.4) in the patients with sporadic duodenal adenoma compared to that in the control group. Also, the incidence of colorectal cancer was higher in sporadic duodenal adenoma patients compared to that in the population (P= 0.02).

CONCLUSIONS

Individuals with sporadic duodenal adenomas appear to be at a significantly higher risk of colorectal neoplasia, and therefore should undergo colonoscopy.

Ghrelin Levels in Gastric Mucosa before and after Eradication of Helicobacter pylori

BACKGROUND/AIMS

The relationship between Helicobacter pylori infection and ghrelin is controversial. We compared ghrelin levels in gastric mucosa and plasma between H. pylori-positive and -negative subjects, and between before and after H. pylori eradication.

METHODS

We compared the ghrelin levels in the antrum, body, and fundus between H. pylori-positive and -negative subjects; in stomach tissues between before and after H. pylori eradication; and in plasma and tissue in 10-person cohorts between before and after H. pylori eradication therapy. Body mass index, age, and sex were controlled for when comparing ghrelin levels.

RESULTS

Stomach ghrelin levels (in the antrum, body, and fundus) did not differ significantly between H. pylori-positive and -negative samples (p=0.095, 0.316, and 0.897, respectively), or between before and after H. pylori eradication (p=0.19, 0.178, and 0.513, respectively). In the ten-person cohort study, plasma ghrelin levels in the eight H. pylori-positive subjects were 2,260 pg/mL (range, 1,280-3,770 pg/mL) and 1,900 pg/mL (range, 1,350-5,200 pg/mL) before and after eradication therapy (p=0.871). Stomach ghrelin levels did not differ significantly in the eight H. pylori-positive subjects between before and after H. pylori eradication (p=0.732, 0.618, and 0.435 in the antrum, body, and fundus, respectively), or between six eradicated and two noneradicated subjects (p=0.071, 0.857, 0.429, and 0.857 in the antrum, body, fundus, and plasma, respectively).

CONCLUSIONS

These results show that H. pylori infection has no effect on stomach ghrelin levels and that eradication therapy does not influence plasma or tissue ghrelin levels.

Patients with sporadic duodenal adenoma are a high-risk group for advanced colorectal neoplasia: results of a case-control study

AIM

To evaluate colorectal cancer risk among patients with sporadic duodenal neoplasia using a case-control protocol.

METHODS

Cases were 35 patients referred for the management of sporadic duodenal adenoma and who underwent colonoscopy. Colonoscopy findings among cases were compared with those from a control group matched for age and sex (two controls per case) without duodenal adenoma. Colonoscopy findings were categorized as adenoma, advanced adenoma, cancer or advanced neoplasia. The two groups were compared using the chi-squared test. Odds ratio and 95% confidence intervals were calculated.

RESULTS

Colorectal adenoma was present in 31% of cases vs. 24% of controls, advanced neoplasia in 29% vs. 4%, advanced adenoma in 23% vs. 3% and adenocarcinoma in 6% vs. 1%. The relative risks of advanced colorectal adenoma and advanced colorectal neoplasia in cases were 10.1 (95% CI: 1.8-100.1, P = 0.003) and 8.9 (95% CI: 2.1-53.3, P = 0.001), respectively.

CONCLUSIONS

The relative risk of advanced colorectal adenoma and advanced neoplasia in cases was nine- to 10-fold that among controls. Patients with sporadic duodenal adenoma represent a high-risk group for advanced colorectal neoplasia and should therefore undergo complete colonoscopy.

Serum ghrelin levels and risk of subsequent adenocarcinoma of the esophagus

OBJECTIVE

Several large studies have shown a negative association between Helicobacter pylori (H. pylori) infection and esophageal adenocarcinoma. Diminution of gastric ghrelin secretion by H. pylori could protect against esophageal malignancy by decreasing appetite, food intake, and acid production, thereby decreasing weight and gastroesophageal reflux.

METHODS

We evaluated the association of ghrelin with esophageal adenocarcinoma using a population from a previous nested case-control study. Among 128,992 enrolled in a multiphasic health checkup (MHC) between 1964 and 1969, 52 patients developed esophageal adenocarcinoma by the year 2000. Three random controls from the MHC cohort were matched to each case by age, sex, race, and the date and site of their MHC. Serum samples collected at the MHC had been previously tested for IgG antibodies against H. pylori and the CagA protein. Serum ghrelin concentrations were determined by a commercial EIA on 52% of the initial subjects (31 cases and 79 controls).

RESULTS

A concentration of ghrelin greater than 3,200 pg/mL at MHC (fourth quartile) was associated with a lower risk of esophageal cancer (H. pylori and body mass index [BMI] adjusted OR=0.18 [CI 0.04-0.78]). This inverse association was seen only in overweight subjects (BMI>or=25, P value for interaction=0.09). The effects of H. pylori and ghrelin were independent.

CONCLUSION

Contrary to the original hypothesis, high rather than low serum ghrelin was associated with protection against esophageal adenocarcinoma but only among overweight subjects.

Effect of Helicobacter pylori infection on ghrelin expression in human gastric mucosa

OBJECTIVES

One of the counter-effects of Helicobacter pylori eradication therapy is subsequent obesity. Ghrelin is a recently discovered growth hormone releasing peptide. This endogenous secretagogue increases appetite and facilitates fat storage. The majority of circulating ghrelin is produced in the gastric mucosa. Therefore, we aimed at investigating changes in ghrelin immunoreactivity in gastric mucosa tissues of patients infected with H. pylori.

METHODS

Sixty-one patients with H. pylori infection (25 cases each of duodenal and gastric ulcer, and 11 cases of gastritis) and 22 healthy controls without H. pylori infection were included in the study. H. pylori-infected patients received standard proton pump-based triple therapy followed by histological examination and (13)C-urea breath test to confirm H. pylori eradication. H. pylori was eradicated in 50 out of 61 patients. Biopsy specimens were obtained from antrum and corpus before and 3 months following eradication. Ghrelin expression was evaluated immunohistochemically with an anti-ghrelin antibody, and the number of ghrelin-positive cells determined per 1 mm(2) of the lamina propria mucosa.

RESULTS

There was no relationship between ghrelin immunoreactivity and body weight or body mass index for healthy controls. The number of ghrelin-positive cells was significantly lower for H. pylori-infected patients than for healthy controls. However, the ghrelin-positive cell number increased significantly following H. pylori eradication without significant change in severity of atrophy.

CONCLUSIONS

These data indicated that H. pylori infection affected ghrelin expression. After H. pylori eradication, gastric tissue ghrelin concentration increased significantly. This could lead to the increased appetite and weight gain seen following H. pylori eradication.

Evaluation and management of periampullary tumors

Periampullary cancers make up 5% of all gastrointestinal cancers. The complexity of the periampullary anatomy makes determination of the origin of some of these tumors difficult. However, advances in imaging have helped with diagnosis as well as defining the extent of the lesion and its potential resectability. For many of these tumors, surgery is the recommended treatment. However, endoscopic removal is being extended to different lesions with encouraging preliminary results. Improvements in overall prognosis for periampullary tumors will be limited until diagnosis can be established earlier in the course of the disease and adjuvant therapies become more effective.