Delayed bleeding after endoscopic submucosal dissection for non-ampullary superficial duodenal neoplasias might be prevented by prophylactic endoscopic closure: analysis of risk factors

Emergency pancreatoduodenectomy for non-traumatic conditions: a case series analysis

BACKGROUND

Emergency pancreaticoduodenectomy (EPD) is an uncommon abdominal surgical procedure primarily performed in patients with severe acute abdominal trauma. Performing EPD requires strict surgical criteria, advanced technical expertise, and comprehensive postoperative management. Limited research exists regarding the indications for non-traumatic EPD. Thus, the objective of this study was to synthesize and analyze recent cases of non-traumatic EPD, thereby enhancing the comprehension of this urgent surgical measure.

METHODS

A retrospective analysis was conducted on patients who underwent non-traumatic EPD at the 900th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army from January 2013 to September 2023. The study assessed preoperative etiologies, intraoperative findings, postoperative complications, and prognosis. Additionally, a literature review was performed.

RESULTS

Nine patients underwent non-traumatic EPD. All patients demonstrated clear indications for emergency surgery: three cases of gastrointestinal hemorrhage secondary to ulcerative lesions, three cases of perforation (n = 2) and bleeding (n = 1) following invasive endoscopic procedures for neoplastic lesions, two cases of tumor rupture-related hemorrhage, and one case of postoperative anastomotic bleeding. All patients completed the surgical procedure. The operative duration ranged from 185.0 to 480.0 min, with a mean of 299.9 ± 83.3 min, and intraoperative blood loss ranged from 100.0 to 6,000.0 ml, with a mean of 1,477.8 ± 1,944.7 ml. Postoperative pathology revealed that 3 cases involved benign ulcerative lesions of the digestive tract and 6 cases involved neoplastic lesions in the pancreaticoduodenal region. One patient died 6 days postoperatively due to multiple organ failure, another died 42 days postoperatively due to tumor progression, and the remaining 7 patients recovered and were discharged, with a postoperative hospital stay of 17-45 days, mean 36.3 ± 10.5 days. Postoperative complications occurred in six patients (85.7%), including pancreatic fistula, biliary fistula, and abdominal infection, all of which resolved with conservative management.

CONCLUSION

In cases of non-traumatic emergencies in the pancreaticoduodenal region where conservative or minimally invasive treatments fail to control the acute progression, EPD serves as a critical surgical intervention that may save lives and yield favorable outcomes.

Case Report: Rare duodenal schwannoma diagnosis and treatment process report

Background

Duodenal schwannoma is a rare benign mesenchymal tumor originating from the Schwann cells of peripheral nerves. Its accurate diagnosis remains challenging owing to non-specific clinical and radiological features.

Case presentation

This report describes the clinical diagnosis and treatment of a duodenal schwannoma in a 30-year-old female patient. An initial outpatient gastroscopy revealed a submucosal lesion in the duodenum, with differential diagnoses including ectopic pancreas or gastrointestinal stromal tumor. Furthermore, plain and contrast-enhanced abdominal CT scans showed a nodule protruding into the duodenal bulb, suggesting a benign lesion. The patient underwent endoscopic submucosal dissection to remove the tumor. During the procedure, a 1.0 × 1.6 cm submucosal nodule was identified on the anterior wall of the duodenal bulb, with a mildly eroded and slightly depressed surface. The lesion was firm and non-mobile. Histopathological examination of the resected specimen confirmed a spindle cell tumor originating from the duodenal mucosa, leading to a definitive diagnosis of duodenal schwannoma.

Conclusion

Duodenal schwannoma is a rare submucosal tumor traditionally treated with surgical resection. This case highlights the safety and efficacy of endoscopic submucosal dissection in the treatment of duodenal schwannomas, allowing complete tumor resection while preserving gastrointestinal function. In addition, early detection and complete resection are key for preventing recurrence and potential complications.

Association between prophylactic closure of mucosal defect and delayed adverse events after endoscopic resection: a systematic review and meta-analysis

OBJECTIVE

To investigate the potential of prophylactic closure of mucosal defects to prevent adverse events following endoscopic resection of superficial layers of the gastrointestinal (GI) wall.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched PubMed, Embase, Web of Science and the Cochrane Library for studies eligible for inclusion in our meta-analysis from inception to February 2022.

DATA EXTRACTION AND SYNTHESIS

We compared the effects of closure versus non-closure of mucosal defects with respect to adverse events including delayed bleeding, delayed perforation and postpolypectomy coagulation syndrome (PPCS). We used a random-effects model for all analyses. Subgroup analyses were performed based on gastrointestinal sites, surgical procedures and study designs.

RESULTS

In total, this study includes 11 383 patients from 28 studies. For delayed bleeding, closure group was associated with a lower incidence (Risk Ratio [RR]: 0.40, 95% Confidence interval [CI]: 0.30 to 0.53, p<0.001; I2=25%) and consistent results were observed in the subgroups. Also, for delayed perforation, a combined analysis of all sites and surgical methods showed a protective effect of prophylactic closure of mucosal defects (RR: 0.42, 95% CI: 0.22 to 0.82, p=0.01; I2=0%). Similar results were observed in the subgroup analyses, despite the wide CIs. Regarding the PPCS, neither the pooled RRs nor the subgroup analyses showed significant differences.

CONCLUSION

Prophylactic closure of mucosal defects is beneficial in reducing the incidence of delayed bleeding and delayed perforation after endoscopic resection, but there is no significant difference in reducing the incidence of PPCS.

Same duodenal neuroendocrine tumors, different endoscopic resection methods: a case report and literature review

Duodenal neuroendocrine tumors (NETs), comprising 2-3% of all gastrointestinal NETs and 1-3% of all duodenal tumors, are remarkably uncommon. In this report, we described a patient diagnosed with two submucosal tumors in the duodenal bulb. We used two distinct endoscopic resection methods, including endoscopic submucosal dissection (ESD) and submucosal tunneling endoscopic resection (STER), to achieve en bloc resection of the lesions without complications. Pathological evaluation, involving hematoxylin-eosin staining and immunohistochemistry, confirmed the diagnosis of NET. Given the limited operative field and space in the duodenal bulb, STER proved to be a viable endoscopic resection technique.

Aspiration and coagulation to reduce risk of delayed bleeding after gastric endoscopic submucosal dissection (with video)

OBJECTIVES

The purpose of this study was to evaluate the feasibility of a simple method named aspiration and coagulation (AC) for reducing the risk of postoperative bleeding after gastric endoscopic submucosal dissection (ESD).

METHODS

Data were retrospectively reviewed and collected from the medical records and endoscopic and pathologic reports about consecutive patients who underwent ESD for early gastric cancer or precancerous lesions or gastric submucosal lesions from January 2016 to December 2021 at the Seventh Medical Center of Chinese PLA General Hospital. Enrolled patients who underwent the AC method during ESD were included in the AC group, and the others were included in the control group. Propensity score (PS) matching (1:1 match) was used to compensate for the differences that might affect post-ESD bleeding. Massive hemorrhage and overall delayed bleeding events after gastric ESD were compared between the two groups.

RESULTS

Propensity score matching analysis created 242 matched pairs in the study. Characteristics of the subjects such as age and use of antithrombotic drugs were all similar between the two groups after PS matching. The rate of massive hemorrhage and overall delayed bleeding was both significantly lower in the AC group than in the control (0.4% vs. 3.3% for massive hemorrhage, P = 0.037, and 1.2% vs. 5.0% for overall delayed bleeding, P = 0.032), predominantly in mucosal lesions (0.6% vs. 4.4% for massive hemorrhage, P = 0.032, and 1.2% vs. 5.6% for overall delayed bleeding, P = 0.031).

CONCLUSIONS

Our study demonstrated that the AC method effectively decreased delayed bleeding events after ESD.

A first-in-human clinical study of laparoscopic autologous myoblast sheet transplantation to prevent delayed perforation after duodenal endoscopic mucosal dissection

BACKGROUND

The detection rate of superficial non-ampullary duodenal epithelial tumors (SNADETs) has recently been increasing. Large tumors may contain malignant lesions and early therapeutic intervention is recommended. Endoscopic mucosal dissection (ESD) is considered a feasible treatment modality, however, the anatomical and physiological characteristics of the duodenum create a risk of postoperative perforation after ESD.

METHODS

To explore whether myoblast sheet transplantation could prevent delayed perforation after ESD, a first-in-human (FIH) clinical trial of laparoscopic autologous myoblast sheet transplantation after duodenal ESD was launched. Autologous myoblast sheets fabricated from muscle tissue obtained seven weeks before ESD were transplanted laparoscopically onto the serous side of the ESD. The primary endpoints were the onset of peritonitis due to delayed perforation within three days after surgery and all adverse events during the follow-up period.

RESULTS

Three patients with SNADETs ≥ 20 mm in size underwent transplantation of a myoblast sheet onto the serous side of the duodenum after ESD. In case 1, The patient's postoperative course was uneventful. Endoscopy and abdominal computed tomography revealed no signs of delayed perforation. Despite incomplete mucosal closure in case 2, and multiple micro perforations during ESD in case 3, cell sheet transplantation could prevent the postoperative massive perforation after ESD, and endoscopy on day 49 after transplantation revealed no stenosis.

CONCLUSIONS

This clinical trial showed the safety, efficacy, and procedural operability of this novel regenerative medicine approach involving transplanting an autologous myoblast sheet laparoscopically onto the serosa after ESD in cases with a high risk of delayed perforation. This result indicates the potential application of cell sheet medicine in treating various abdominal organs and conditions with minimal invasiveness in the future.

TRIAL REGISTRATION

jRCT, jRCT2073210094. Registered November 8 2021, https://jrct.niph.go.jp/latest-detail/jRCT2073210094 .

Clinical outcomes of the over-the-scope clip closure after duodenal endoscopic submucosal dissection: A multicenter retrospective study

BACKGROUND AND AIM

Prophylactic closure with the over-the-scope clip (OTSC) after endoscopic submucosal dissection (ESD) of superficial non-ampullary duodenal epithelial tumors (SNADETs) has been reported to reduce postoperative adverse events (AEs). However, there are few evidences regarding AEs-associated factors and long-term outcomes of OTSCs.

METHODS

From January 2011 to December 2020, 139 consecutive patients with SNADETs who underwent ESD followed by OTSC closure in five institutions were extracted in this retrospective study. The primary endpoint was the rate of postoperative AEs after prophylactic OTSC closure. The secondary endpoints were the complete closure rate, residual rate, and long-term AEs associated with residual OTSCs.

RESULTS

The rate of complete closure of the mucosal defect was 97.3% (142) in 146 SNADETs, which were completely resected by ESD. Postoperative AEs, including delayed bleeding, delayed perforation, and localized peritonitis, occurred in 6.2%, 3.4%, and 2.1% of patients, respectively; however, all of the cases improved without surgical treatment. In the multivariate logistic regression analysis, the use of two or more OTSCs was a significant independent risk factor for postoperative AEs (odds ratio, 2.94; 95% confidence interval, 1.02-8.46; P = 0.046). The residual OTSC rate was 46.4% at 1 year postoperatively, and long-term AEs included duodenal erosions and ulcers associated with residual OTSCs.

CONCLUSIONS

Prophylactic closure with OTSCs after duodenal ESD can provide acceptable short-and long-term outcomes for preventing postoperative AEs. However, multiple OTSCs were the independent risk factors of postoperative AEs due to the gaps between and near the OTSCs.

Efficacy and safety of precutting endoscopic mucosal resection versus endoscopic submucosal dissection for non-ampullary superficial duodenal lesions

BACKGROUND

Endoscopic treatments for non-ampullary superficial duodenal lesions (NASDLs) are yet to be standardized. Endoscopic submucosal dissection (ESD) for NASDLs demands advanced techniques and a long procedure time to prevent perforation and bleeding. Precutting endoscopic mucosal resection (EMR) is a technical modification of ESD that overcomes the limitations of ESD. This study aimed to compare the efficacy and safety of precutting EMR versus ESD for NASDLs.

METHODS

We conducted a retrospective analysis of patients with NASDLs treated with either precutting EMR or ESD from January 2015 to March 2023.

RESULTS

A total of 90 patients with NASDLs were analyzed, with 44 patients in the precutting EMR group and 46 patients in the ESD group. The endoscopic procedure achieved satisfactory outcomes in both groups, with en block resection rate of 100.0 %. The R0 resection rates in the precutting EMR and ESD groups were 95.5 % and 93.5 %, respectively. No delayed perforation occurred postoperatively in either group. There were no significant differences between the two groups in age, gender, lesion location, layer of lesion origin, macroscopic type, and lesion size. The procedure time was significantly shorter in the precutting EMR group than in the ESD group (22.9 ± 7.1 min vs 36.0 ± 10.6 min, p<0.001). The intraoperative perforation rate was significantly lower in the precutting EMR group compared to ESD group (4.5% vs 19.6 %, p = 0.030).

CONCLUSIONS

Precutting EMR is comparable to ESD for NASDLs, demonstrating a lower intraoperative perforation rate and shorter procedure time compared to ESD.

Usefulness of the S-O clip for duodenal endoscopic submucosal dissection: a propensity score-matched study

BACKGROUND/AIMS

Endoscopic submucosal dissection (ESD) for superficial non-ampullary duodenal tumors (SNADETs) is associated with a high rate of en bloc resection. However, the technique for ESD remains challenging. Recent studies have demonstrated the effectiveness of S-O clips in colonic and gastric ESD. We evaluated the efficacy and safety of duodenal ESD using an S-O clip for SNADETs.

METHODS

Consecutive patients who underwent ESD for SNADETs between January 2011 and December 2021 were retrospectively enrolled. Propensity score matching analysis was used to compare patients who underwent duodenal ESD with the S-O clip (S-O group) and those who underwent conventional ESD (control group). Intraoperative perforation rate was the primary outcome, while procedure time and R0 resection rate were the secondary outcomes.

RESULTS

After propensity score matching, 16 pairs were created: 43 and 17 in the S-O and control groups, respectively. The intraoperative perforation rate in the S-O group was significantly lower than that in the control group (p=0.033). A significant difference was observed in the procedure time between the S-O and control groups (39±9 vs. 82±30 minutes, respectively; p=0.003).

CONCLUSION

The S-O clip reduced the intraoperative perforation rate and procedure time, which may be useful and effective in duodenal ESD.

Role of Advanced Gastrointestinal Endoscopy in the Comprehensive Management of Neuroendocrine Neoplasms

Neuroendocrine neoplasms (NENs), also called neuroendocrine tumors (NETs), are relatively uncommon, heterogenous tumors primarily originating in the gastrointestinal tract. With the improvement in technology and increasing use of cross-sectional imaging and endoscopy, they are being discovered with increasing frequency. Although traditionally considered indolent tumors with good prognoses, some NENs exhibit aggressive behavior. Timely diagnosis, risk stratification, and management can often be a challenge. In general, small NENs without local invasion or lymphovascular involvement can often be managed using minimally invasive advanced endoscopic techniques, while larger lesions and those with evidence of lymphovascular invasion require surgery, systemic therapy, or a combination thereof. Ideal management requires a comprehensive and accurate understanding of the stage and grade of the tumor. With the recent advancements, a therapeutic advanced endoscopist can play a pivotal role in diagnosing, staging, and managing this rare condition. High-definition white light imaging and digital image enhancing technologies like narrow band imaging (NBI) in the newer endoscopes have improved the diagnostic accuracy of traditional endoscopy. The refinement of endoscopic ultrasound (EUS) over the past decade has revolutionized the role of endoscopy in diagnosing and managing various pathologies, including NENs. In addition to EUS-directed diagnostic biopsies, it also offers the ability to precisely assess the depth of invasion and lymphovascular involvement and thus stage NENs accurately. EUS-directed locoregional ablative therapies are increasingly recognized as highly effective, minimally invasive treatment modalities for NENs, particularly pancreatic NENs. Advanced endoscopic resection techniques like endoscopic submucosal dissection (ESD), endoscopic submucosal resection (EMR), and endoscopic full-thickness resection (EFTR) have been increasingly used over the past decade with excellent results in achieving curative resection of various early-stage gastrointestinal luminal lesions including NENs. In this article, we aim to delineate NENs of the different segments of the gastrointestinal (GI) tract (esophagus, gastric, pancreatic, and small and large intestine) and their management with emphasis on the endoscopic management of these tumors.

Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of  > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection.

Analysis of risk factors for post-endoscopic papillectomy bleeding

BACKGROUND

Endoscopic papillectomy (EP) is an effective treatment for ampullary lesions but technically challenging because of anatomical specificities concerning the high rate of adverse events. Bleeding is one of the most feared complications and can be potentially life-threatening.

AIM

To study the risk factors for bleeding after EP are presented with the goal of establishing preventive measures.

METHODS

A total of 173 consecutive patients with ampullary lesions undergone EP from January 2006 to October 2020 were enrolled in this study. They were divided into a bleeding group and a non-bleeding group depending on whether postoperative bleeding occurred. Related factors were analyzed by univariate and multivariate logistics regression.

RESULTS

Postoperative bleeding was experienced in 33 patients (19.07%). Multivariate analysis also identified intraoperative bleeding (OR: 4.38, 95% CI: 1.87-11.15, p = .001) and endoscopic closure (OR: 0.25, 95% CI: 0.10-0.58, p = .001) as independent factors significantly associated with bleeding after EP. Lesion size (≥3 cm) was shown as an independent factor significantly associated with intraoperative bleeding (OR: 4.25, 95% CI: 1.21-16.44, p = .028).

CONCLUSIONS

This retrospective evaluation found that endoscopic closure was associated with reduced risk and intraoperative bleeding with increased risk of bleeding after EP. Lesion size may indirectly influence the risk of postoperative bleeding by increasing the risk of intraoperative bleeding.

Survival comparison between endoscopic and surgical resection for non-ampullary duodenal neuroendocrine tumor (1-2 cm)

The treatment plan for non-ampullary duodenal neuroendocrine tumors (d-NETs) with diameters 1-2 cm remains controversial. We therefore aimed to compare the prognostic effects of endoscopic treatment and surgical resection on non-ampullary d-NETs with 1-2 cm diameters. A total of 373 eligible patients were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was performed to match patients 1:1 according to clinicopathological characteristics. Disease-specific survival (DSS) and overall survival (OS) were calculated. Before PSM, there was no significant difference in DSS or OS (all P > 0.05), but the T stage, N stage, and TNM stage were significantly different between the two surgical methods (all P < 0.05). After 1:1 PSM, the differences in clinicopathological characteristics were significantly reduced (all P > 0.05). Survival analysis showed that tumor grade was correlated with DSS and that age was correlated with OS (all P < 0.05); however, the surgical method and other clinicopathological characteristics were not correlated with prognosis (all P > 0.05). Subgroup survival analysis of patients with T2N0M0 disease and tumors invading the lamina propria or submucosa showed that the 5-year DSS and OS rates were not significantly different according to the surgical approach (all P > 0.05). The surgical approach has no significant effect on the prognosis of patients with non-ampullary d-NETs with 1-2 cm diameters, especially those with T2N0M0 disease. This suggests that endoscopic treatment may be a preferred option for these patients.

Endoscopic resection via antral submucosal tunneling for en bloc removal of tumors in the duodenal bulb

To overcome difficulties in the removal of duodenal bulb lesions, especially those in anatomically challenging locations, we developed the endoscopic resection via antral submucosal tunneling (ERAST) technique. In this study, we evaluated the feasibility and safety of ERAST for the removal of superficial and subepithelial lesions in the duodenal bulb. This was a single-center retrospective study of 10 patients with lesions in the bulb. Submucosal tunneling from the gastric antrum to the duodenum was performed to facilitate en bloc tumor resection in the bulb. The en bloc resection rate, postoperative bleeding, and perforation were the primary endpoints. Ten lesions (four superficial and six subepithelial), with an average size of 19.1 ± 9.2 mm, were resected en bloc by ERAST. Esophagogastroduodenoscopy follow-up after 2 months indicated complete wound healing in all patients. In our primary experience, ERAST was found to be a feasible and safe endoscopic resection technique for the removal of lesions in the duodenal bulb, especially those that are difficult to access.

Clinical Efficacy of Endoscopic Submucosal Dissection for the Treatment of Duodenal Lesions in Terms of Operative Technique and Management of Complications

Background and Aims: Duodenal endoscopic submucosal dissection (ESD) has been considered to be the most challenging because of its high incidence of complications, which has hindered the development of duodenal ESD. The aim of this study is to discuss operation tips for duodenal ESD and to assess the efficacy and safety of duodenal ESD. Patients and Methods: Eighty-two patients who underwent ESD in the digestive endoscope center for superficial duodenal epithelial tumors (SDETs) from January 2017 to June 2021 were studied. Patients were divided into three groups according to the occurrence of complications, and the clinical characteristics and surgical efficacy of each group were compared. Results: SDETs in 82 patients were completely removed by ESD, with a 97.5% R0 resection rate. The average size of resected lesions was 23.8 ± 6.5 mm. There were significant differences in lesion size and operation time between the normal and intraprocedural complication groups (P < .05). Similarly, between the normal and delayed complication groups, significant differences were noted in lesion location, size, operation time, occupied circumference, and postoperative hospitalization duration (P < .05). Conclusion: Duodenal ESD is prone to complications that increase the complexity of the procedure. By improving the necessary technique and skills, duodenal ESD remains safe and effective.

Sporadic non-ampullary duodenal adenoma with low-grade dysplasia: Natural history and clinical management

Background and study aims  Management strategies for sporadic non-ampullary duodenal adenoma with low-grade dysplasia (LGD) are not well established. This study aimed to analyze progression factors and determine suitable treatment strategies for LGD lesions. Patients and methods  We retrospectively analyzed consecutive LGD lesions (n = 125) in patients followed up for ≥ 6 months (median, 45 months) and evaluated the changes in clinicopathological features during follow-up. All LGD lesions were classified into two groups: stable LGD (no increase or < 5 mm increase in tumor size, with unchanged histological dysplasia grade) and progressive LGD (≥ 5 mm increase in tumor size and/or progression to high-grade dysplasia or adenocarcinoma). Results  Eighty-six LGD were classified as stable and 39 as progressive. Location on the oral side of the papilla of Vater, large initial tumor size ( ≥ 10 mm), macroscopically complex type, red color, and nodularity were significantly frequent in progressive LGD than in stable LGD. In multivariate analysis, large initial tumor size (odds ratio [OR], 10.2; 95 % confidence interval [CI], 3.3-32.1; P  < 0.001) and location on the oral side of the papilla of Vater (OR: 1.8, 95 % CI: 1.4-12.5; P  = 0.012) were significant factors for progression. Moreover, initial tumor size < 5 mm rarely progressed (0%-3.9 %); however, initial tumor size ≥ 20 mm and 10-19 mm located on the oral side of the papilla of Vater had a high-risk progression rate (75.0-85.7 %). Conclusions  According to the risk stratification of progression factors by initial tumor size and location, we can determine suitable treatment indications for LGD lesions.

Feasibility of endoscopic resection for large pedunculated duodenal lesions (with video)

BACKGROUND

A standard treatment method for pedunculated duodenal lesions has not yet been established. This study aimed to evaluate the feasibility of endoscopic resection (ER) for pedunculated duodenal lesions, especially for large lesions.

METHODS

This study retrospectively reviewed cases of pedunculated duodenal lesions treated with ER at our institute between July 2010 and January 2021. We collected data on the clinical characteristics and treatment outcomes. In addition, the cases were divided based on the treatment provided for the lesion, i.e., the ESD and snare resection groups, and we compared the data between the two groups.

RESULTS

Thirty-eight cases were included in this study. The overall en bloc resection rate was 95%. No perforation occurred in any of the cases. There were 10 cases treated with ESD, which were considered difficult to achieve en bloc resection using snare forceps, and 28 cases treated with snare resection. Although the median lesion size was significantly larger in the ESD group than in the snare resection group (27 [range 23-66] vs. 19 [range 6-55] mm, P = 0.0052), treatment outcomes were not significantly different between the two groups. Among the 10 cases treated using ESD, en bloc resection was achieved in all cases, along with specimen retrieval without any perforations, despite the large size of the lesions.

CONCLUSION

ER could be performed to achieve a high en bloc resection rate without any perforations in pedunculated duodenal lesions, even in extremely large (e.g., ≧ 60 mm) lesions, suggesting that ER is feasible and may be an alternative to surgical resection for large pedunculated duodenal lesions.

Safety of Endoscopic Mucosal Resection Using a Bipolar Snare for Superficial Nonampullary Duodenal Epithelial Tumors and the Predictive Factors of Piecemeal Resection

INTRODUCTION

Endoscopic mucosal resection for small superficial nonampullary duodenal epithelial tumors is a noninvasive treatment; however, perforations can occur. Bipolar snares can reduce the risk of perforation due to small tissue damage. Currently, only few studies have reported endoscopic mucosal resection for small superficial nonampullary duodenal epithelial tumors using a bipolar snare and the effect of preoperative findings.

OBJECTIVE

To investigate (1) resectability and adverse events of endoscopic mucosal resection using a bipolar snare for small superficial nonampullary duodenal epithelial tumors and (2) the predictions of piecemeal resection.

METHODS

Between 2007 and 2017, 89 patients with 107 lesions underwent endoscopic mucosal resection using a bipolar snare. Among them, 88 lesions of 77 patients were evaluated. The primary outcome was the incidence of en bloc resection and R0 resection and adverse events. Risk factors associated with piecemeal resection, including preoperative lesion findings, were also examined.

RESULTS

The incidence rates of en bloc and R0 resections were 85.2 and 48.9%, respectively. Neither intraoperative or delayed perforations nor procedure-related mortality was noted. The nonlifting sign after submucosal injection was associated with an increase in piecemeal resection (odds ratio: 20.3, 95% confidence interval: 2.53-162; p = 0.005).

CONCLUSION

Endoscopic resection for small superficial nonampullary duodenal epithelial tumors can cause perforation; however, endoscopic mucosal resection using a bipolar snare can be a safe treatment option as it does not cause perforations. The nonlifting sign after submucosal injection is a predictive factor for piecemeal resection.

External drainage of bile and pancreatic juice after endoscopic submucosal dissection for duodenal neoplasm: Feasibility study (with video)

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) for superficial duodenal epithelial tumors (SDETs) is technically difficult and has a high risk of adverse events. Endoscopic nasobiliary and nasopancreatic duct drainage (ENBPD) may reduce the risk of delayed adverse events by preventing exposure of the post-ESD mucosal defect to bile and pancreatic juice. This study was performed to evaluate the safety and feasibility of ENBPD after duodenal ESD.

METHODS

Patients who underwent ESD for SDETs from July 2010 to March 2020 were included. We collected data on the success rate of ENBPD, adverse events due to insertion of a side-viewing endoscope, and pancreatitis after ENBPD. We also collected the clinical outcomes of duodenal ESD, including the incidence rate of delayed adverse events (defined as bleeding or perforation found after the endoscopic procedure).

RESULTS

Among 70 patients without complete closure of the post-ESD mucosal defect, ENBPD was successfully performed in all 25 patients including 21 cases inserted immediately after ESD and four cases inserted later. There were no adverse events associated with ENBPD procedure intraoperatively, while pancreatitis after ENBPD occurred in four patients (16.0%). No patients who underwent immediate ENBPD required intervention for an intra-abdominal abscess or delayed perforation, whereas 3 of 49 patients (6.1%) who did not undergo immediate ENBPD required surgery or drainage of an abscess.

CONCLUSIONS

Endoscopic nasobiliary and nasopancreatic duct drainage is technically feasible and might provide effective prophylaxis for delayed adverse events, even if a large mucosal defect is present after ESD.

The Use of Endoscopic Clipping in Preventing Delayed Complications after Endoscopic Resection for Superficial Non-Ampullary Duodenal Tumors

BACKGROUND/AIMS

Endoscopic resection (ER) has recently been accepted as the standard treatment modality for superficial nonampullary duodenal tumors (SNADTs). However, the procedure can cause adverse events such as perforation and bleeding. This study aimed to investigate the efficacy of prophylactic clipping in the prevention of delayed complications.

METHODS

A retrospective review of the medical records of patients who underwent ER for SNADT from 3 centers was performed. Patients were divided into 2 groups: the immediate clipping group (ICG) and the no clipping group (NCG). Various baseline characteristics and factors associated with the appearance of delayed complications, such as size of the lesion, tumor location, histologic type, and co-morbidities, were compared between the two groups.

RESULTS

A total of 99 lesions from 99 patients were included in this study. Fifty-two patients were allocated into ICG and 47 patients were allocated into NCG. Delayed bleeding occurred in 1 patient from ICG and in 8 patients from NCG. Delayed perforation occurred in 1 patient from ICG and in 3 patients from NCG. There were no procedure-related deaths in both groups.

CONCLUSION

Although the use of endoscopic clipping seemed to reduce the risk of developing delayed complications, further studies using a prospective design is required.

Prevention and Management of Complications and Education in Endoscopic Submucosal Dissection

Endoscopic submucosal dissection (ESD) is considered superior to endoscopic mucosal resection as an endoscopic resection because of its higher en bloc resection rate, but it is more difficult to perform. As ESD techniques have become more common, and the range of treatment by ESD has expanded, the number of possible complications has also increased, and endoscopists need to manage them. In this report, we will review the management of critical complications, such as hemorrhage, perforation, and stenosis, and we will also discuss educational methods for acquiring and improving ESD skills.

Pre-ampullary location and size ≥10 mm are independent predictors for high-grade superficial non-ampullary duodenal epithelial tumors

BACKGROUND AND AIM

The incidence of identified superficial non-ampullary duodenal epithelial tumors (SNADETs) has been increasing with recent advances in endoscopic diagnosis. Nevertheless, the clinical features of SNADETs with malignant potential remain unclear. The aim of the present study was to clarify the clinical characteristics of high-grade SNADETs.

METHODS

A total of 328 SNADETs that had been endoscopically or surgically resected between January 2013 and April 2019 were identified from an endoscopic and pathological database. Clinical characteristics were compared between mucosal low-grade neoplasm (n = 154) and mucosal high-grade neoplasm/submucosal carcinoma (HGN/SMC, n = 174).

RESULTS

In univariate analysis, tumor size, pre-ampullary tumor location, red color, and rough/nodular surface were significantly associated with HGN/SMC. In multivariate analysis (odds ratio [95% confidence interval]), large (≥10 mm) tumor size (odds ratio: 4.5, 95% confidence interval: 2.6-7.7, P < 0.001) and pre-ampullary tumor location (odds ratio: 2.1, 95% confidence interval: 1.3-3.5, P = 0.004) were independent predictors for HGN/SMC. Analysis of histological phenotypes revealed that the proportion of tumors that were HGN/SMC was much greater for gastric-type tumors (21/23 lesions, 91%) than for intestinal-type tumors (150/302 lesions, 50%) (P < 0.001) and that all gastric-type tumors were located in the pre-ampullary portion.

CONCLUSIONS

Pre-ampullary location and large tumor size are independent predictors for HGN/SMC SNADETs. Pre-ampullary tumor location is significantly associated with gastric histological phenotype. These findings may help in decision making for endoscopic treatment, active indication for pre-ampullary tumor or tumor ≥10 mm, and understanding the pathophysiology of SNADETs.

Efficacy of Underwater Endoscopic Mucosal Resection for Superficial Non-Ampullary Duodenal Epithelial Tumor

BACKGROUND/AIMS

Endoscopic resection (ER) for superficial non-ampullary duodenal epithelial tumors (SNADETs) is challenging. Conventional endoscopic mucosal resection (CEMR) is also problematic due to the anatomical features of the duodenum. We compared the safety and efficacy of underwater endoscopic mucosal resection (UEMR) with those of CEMR through a retrospective analysis.

METHODS

Altogether, 44 consecutive patients with 46 SNADETs underwent ER (18 CEMR cases and 28 UEMR cases) between January 2016 and October 2019. We investigated the proportions of en bloc resection, R0 resection, complications, resection time, and total procedure time and compared the outcomes of patients from the CEMR group with those of patients from the UEMR group.

RESULTS

The median tumor size was 8.0 mm (range, 2.0-20.0 mm). The UEMR group showed a higher proportion of en bloc resection (96.4% vs. 72.2%, p<0.05) and significantly lower median resection time and total procedure time (4 min vs. 9.5 min, p<0.05 and 13 min vs. 19 min, p<0.05; respectively) than the CEMR group. No complications were observed. However, two patients treated with piecemeal resection in the CEMR group had residual tumors.

CONCLUSION

UEMR is a feasible therapeutic option for SNADETs. It can be recommended as a standard treatment.

Endoscopic management of superficial nonampullary duodenal tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends that all duodenal adenomas should be considered for endoscopic resection as progression to invasive carcinoma is highly likely.Strong recommendation, low quality evidence. 2: ESGE recommends performance of a colonoscopy, if that has not yet been done, in cases of duodenal adenoma.Strong recommendation, low quality evidence. 3: ESGE recommends the use of the cap-assisted method when the location of the minor and/or major papilla and their relationship to a duodenal adenoma is not clearly established during forward-viewing endoscopy.Strong recommendation, moderate quality evidence. 4: ESGE recommends the routine use of a side-viewing endoscope when a laterally spreading adenoma with extension to the minor and/or major papilla is suspected.Strong recommendation, low quality evidence. 5: ESGE suggests cold snare polypectomy for small (< 6 mm in size) nonmalignant duodenal adenomas.Weak recommendation, low quality evidence. 6: ESGE recommends endoscopic mucosal resection (EMR) as the first-line endoscopic resection technique for nonmalignant large nonampullary duodenal adenomas.Strong recommendation, moderate quality evidence. 7: ESGE recommends that endoscopic submucosal dissection (ESD) for duodenal adenomas is an effective resection technique only in expert hands.Strong recommendation, low quality evidence. 8: ESGE recommends using techniques that minimize adverse events such as immediate or delayed bleeding or perforation. These may include piecemeal resection, defect closure techniques, noncontact hemostasis, and other emerging techniques, and these should be considered on a case-by-case basis.Strong recommendation, low quality evidence. 9: ESGE recommends endoscopic surveillance 3 months after the index treatment. In cases of no recurrence, a further follow-up endoscopy should be done 1 year later. Thereafter, surveillance intervals should be adapted to the lesion site, en bloc resection status, and initial histological result. Strong recommendation, low quality evidence.

Endoscopic Treatment for Superficial Nonampullary Duodenal Tumors

Superficial nonampullary duodenal epithelial tumors are considered rare but have been increasingly recognized in recent years. Accordingly, the importance of endoscopic treatment for the lesions are also increasing. An endoscopic resection can be considered for duodenal adenoma and mucosal cancer. The choice of resection method should be made based on the size of the lesion, endoscopic findings, pathologic diagnosis, and risk of procedure-related complication. For small adenomas <10 mm in size, endoscopic mucosal resection (EMR), cold snare polypectomy, and underwater EMR can be considered. An en bloc or piecemeal resection using EMR or underwater EMR can be selected for 10-20 mm sized adenomas. For lesions ≥20 mm in size or suspicious for mucosal cancer, an endoscopic submucosal dissection followed by closure of the mucosal defect conducted by an experienced endoscopist is appropriate.

Appropriate endoscopic treatment selection and surveillance for superficial non-ampullary duodenal epithelial tumors

OBJECTIVES

Superficial nonampullary duodenal epithelial tumors (SNADETs) have become frequently detected and referred for endoscopic resection (ER). However, optimal treatment methods and long-term outcomes after ER of SNADETs have not been fully elucidated. We aimed to clarify them by analyzing our large cohort of patients with SNADETs.

MATERIALS AND METHODS

We enrolled 190 consecutive tumors from 189 patients undergoing ER between January 2004 and September 2019. Cases were stratified into endoscopic submucosal dissection (ESD), conventional endoscopic mucosal resection, (CEMR) and underwater endoscopic mucosal resection (UEMR). Baseline characteristics and short-term outcomes were compared between the groups. Long-term outcomes were also investigated with a median follow-up of 36 months.

RESULTS

ESD significantly exceeded CEMR (96.4% vs. 52.9%; p = .0026) and UEMR (96.4% vs. 50.0%; p = .0008) in complete resection rates for 11- to 20-mm lesions; the differences were not significant for lesions ≤10 mm. Local recurrence only occurred in patients with an incomplete resection. Only patients with submucosal invasion died from the primary neoplasms. The 3- and 5-year disease-free survivals were 91.3% and 83.5%.

CONCLUSIONS

While tumors ≤10 mm seem to be good indications for endoscopic mucosal resection, ESD should be considered for larger tumors to better achieve complete resection. Patients with submucosal invasive carcinomas have a great risk of cancer death. Therefore, a close follow-up and an additional treatment are desirable.

Risk factors of delayed bleeding after endoscopic resection of superficial non-ampullary duodenal epithelial tumors and prevention by over-the-scope and conventional clipping

OBJECTIVES

This study was aimed to reveal risk factors for delayed bleeding after endoscopic resection (ER) of superficial non-ampullary duodenal epithelial tumors (SNADETs) and at exploring measures to prevent this complication.

METHODS

A total of 235 consecutive patients with 249 SNADETs who had undergone ER were enrolled in this study. They were divided into two groups: OTSC group, consisting of the initial 114 cases in which the defects were closed only using OTSCs; and OTSC-c group, consisting of the later 135 cases in which conventional clips were additionally used to cover the inverted submucosa after post-procedure defect closure using OTSCs. The therapeutic outcomes were then compared between the OTSC and OTSC-c groups.

RESULTS

All lesions were successfully resected en-bloc, and the R0 resection rate was 92.4%. The complete defect closure rate was 90.0% and no delayed perforation occurred when successful defect closure was achieved. The rate of delayed bleeding was significantly higher in the OTSC group than in OTSC-c group (11.4% vs. 1.5%, P = 0.001). Multivariate logistic regression analyses revealed that tumor location distal to the ampulla (OR 10.0; 95% CI 1.24-81.0, P = 0.03) and use of a DOAC (OR 8.83; 95% CI 1.13-68.7, P = 0.04) were significant independent predictors of delayed bleeding. Propensity score-matching analysis revealed that additional use of conventional clips was associated with a significantly reduced risk of delayed bleeding (P = 0.003).

CONCLUSIONS

Additional use of conventional clips after prophylactic defect closure using OTSCs appears to be useful to reduce the risk of delayed bleeding after ER of SNADETs. UMIN Clinical Trials (No. 000035478).

The value of endoscopic resection for non-ampullary duodenal lesions: A single-center experience

BACKGROUND

To observe and preliminarily evaluate the efficacy and safety of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) in the treatment of non-ampullary duodenal lesions (NADLs).

METHODS

This retrospective observational study included 84 patients who underwent endoscopic resection (ER) with non-ampullary duodenal lesions, between March 2010 and November 2020, at the Cancer Hospital of the Chinese Academy of Medical Sciences (Beijing, China). Data on patient demographics, therapeutic outcomes, and follow-up results were analyzed.

RESULTS

There were 44 patients undergoing EMR, and 40 patients accepting ESD. The overall en bloc resection rate was 98.8% (83/84). For the neoplastic lesions, the overall en bloc resection rate and curative rate were 98.5% (67/68) and 89.7% (61/68), respectively. The procedure-related bleeding and perforation rates were 2.4% and 10.7%, respectively. Univariate analysis results indicated that the main correlation factor of non-curative pathologic resection was tumor size (p = 0.004) and resection size (P < 0.01). There showed a higher curative rate in patients with tumors less than 25 mm in diameter. Multivariate logistic regression analyses determined that the tumor size (OR 0.935; 95% CI 0.878-0.995; P = 0.035) was associated with non-curative resection. No recurrences were observed in patients who had undergone a complete ER during a follow-up period of 42.8 months (range, 3-127 months).

CONCLUSION

Endoscopic resection is an effective, safe, and feasible treatment for non-ampullary duodenal lesions.

Efficacy of endoscopic preventive procedures to reduce delayed adverse events after endoscopic resection of superficial nonampullary duodenal epithelial tumors: a meta-analysis of observational comparative trials

BACKGROUND AND AIMS

Although various procedures have been used to prevent serious adverse events after endoscopic resection of the duodenum, their effectiveness has not been determined. In this study, we conducted a systematic review and meta-analysis to determine whether endoscopic preventive procedures reduce delayed adverse events.

METHODS

Studies on endoscopic treatment for superficial nonampullary duodenal tumors were selected. We compared the following 2 groups: the closure group, which underwent mucosal sutures and coverage of mucosal defects after resection, and the unclosed group, which did not. The primary outcome was the rate of delayed adverse events, including perforation and bleeding. The pooled risk ratios (RRs) of all outcomes investigated, the 95% confidence intervals (CIs), and P values were calculated.

RESULTS

A total of 438 patients from 4 studies were included in the meta-analysis. The pooled overall adverse event rates in the closure group and unclosed group were 3.6% and 21.1%, respectively. This rate was significantly lower in the closure group (RR, 0.19; 95% CI, 0.10-0.38; P < .01; I2 = 0%), and the rate of delayed bleeding was significantly lower in the closure group (RR, 0.14; 95% CI, 0.06-0.33; P < .01; I2 = 0%). Regarding delayed perforation, the RR in the closure group was 0.39 (95% CI, 0.12-1.32; P = .13; I2 = 0%).

CONCLUSIONS

Preventive procedures significantly reduced the risk of delayed adverse events by more than 80%. After endoscopic resection of the duodenum, the implementation of preventive procedures, including mucosal sutures and coverage of mucosal defects, to delay adverse events is strongly recommended.

Current Challenge: Endoscopic Submucosal Dissection of Superficial Non-ampullary Duodenal Epithelial Tumors

With the widespread use of esophagogastroduodenoscopy in recent years, the detection rate of superficial non-ampullary duodenal epithelial tumors (SNADETs) is increasing. Most SNADETs are early-stage adenocarcinoma or benign conditions, including adenoma. Therefore, endoscopic resection is desirable from the perspective of quality of life. However, endoscopic resection for SNADETs has not yet been established. Endoscopic submucosal dissection (ESD) is the most promising method for the treatment of SNADETs, because ESD provides a high rate of en bloc resection and a low rate of recurrence regardless of the tumor size. However, the difficulty of the procedure and a high rate of severe adverse events including perforation and bleeding have become major problems. Various preventive countermeasures for adverse events, such as use of specific devices, endoscope stabilization methods, and endoscopic closure of the post-ESD ulcer using clips, are reported to reduce the risk of the adverse events of ESD for SNADETs. This article reviews and highlights the current state of ESD for SNADETs and new challenges towards safe and effective ESD.

Life on a knife edge: the optimal approach to the management of perforations during endoscopic submucosal dissection (ESD)

INTRODUCTION

Endoscopic submucosal dissection (ESD) is a well-established procedure that can provide curative resection of malignant and premalignant lesions endoscopically, thereby offering patients an effective non-operative option. Though ESD is safe and highly effective when performed in appropriately selected patients by an experienced ESD expert, it carries risks including intraprocedural and delayed perforation.

AREAS COVERED

This review provides a practical approach to the initial management of perforation to minimize subsequent complications. The importance of prompt recognition of perforation and early intervention cannot be overstated. This review summarizes indications for closure, anatomic considerations impacting closure, and closure techniques. This article also highlights the do's and don'ts of various closure devices, focusing particularly on advanced closure methods, the-over-the-scope clips (OTSCs) and endoscopic suturing.

EXPERT OPINION

As ESD offers surgery-sparing alternatives to patients, advanced closure techniques allow endoscopists to effectively and promptly manage associated complications, improving the possibility of the widespread implementation of ESD in the US. With continued improvements in OTSCs and endoscopic suturing, ESD will become a stalwart of endoscopic management of malignant and premalignant gastrointestinal lesions.

Complication risk despite preventive endoscopic measures in patients undergoing endoscopic mucosal resection of large duodenal adenomas

BACKGROUND : Endoscopic mucosal resection (EMR) is the standard treatment of ampullary and nonampullary duodenal adenomas. EMR of large (10-29 mm) and giant (≥ 30 mm) lesions carries a risk of complications such as delayed bleeding and perforation. Prospective data on duodenal EMR are scarce. This study aimed to evaluate the efficacy of endoscopic procedures (clipping and coagulation of visible vessels) to prevent complications after EMR of large and giant lesions. METHODS : 110 patients with 118 adenomas (29 ampullary and 89 nonampullary) were included prospectively. RESULTS : 15 lesions were small (12.7 %), 68 were large (57.6 %), and 35 were giant (29.7 %). Endoscopic prevention of delayed complications was performed in 81.4 % (n = 96) of all lesions and 94.3 % (n = 33) of giant lesions. Complete resection was achieved in 111 lesions (94.1 %). Complications were 22 delayed bleedings (18.6 %), 3 intraprocedural perforations (2.5 %), 2 delayed perforations (1.7 %), and 1 stricture (0.8 %). Major complications were associated with lesions size ≥ 30 mm (28.6 % vs. 9.6 %; P = 0.02) and ampullary adenomas (27.6 % vs. 11.2 %; P = 0.07). All minor bleeding and 75 % of major bleeding episodes were treated endoscopically; 25 % of major bleedings needed radiologic embolization. Two fatal courses were observed when delayed perforation occurred after EMR of giant lesions. Residual adenoma was detected in 20.4 % at first follow-up. CONCLUSIONS : EMR of giant duodenal neoplasia carries a substantial risk of major complications and recurrences. Resection technique and prevention of delayed complications need to be improved. Further measures should be evaluated in randomized studies.

Innovative therapeutic endoscopy in the upper gastrointestinal tract: Review of Japan Gastroenterological Endoscopic Society Core Sessions

Workshops on "Innovative Therapeutic Endoscopy" for upper gastrointestinal tract diseases were held four times as the Japan Gastroenterological Endoscopic Society (JGES) Core Sessions at the 93rd to 96th Biannual Meetings of the JGES. A total of 48 research presentations (including two invited lectures) were reported, and various discussions were held on these topics. When the research presentations were categorized according to the therapeutic procedure, endoscopic submucosal dissection (ESD) was the most frequent with 28 presentations (58.3%), followed by laparoscopy endoscopy cooperative surgery (LECS) with six presentations (12.5%). When the research presentations were classified by the target organ of the therapeutic procedures, the duodenum was the most frequent with 26 presentations (54.1%), followed by the stomach with 13 presentations (27.1%). The most important issue was the establishment of a safe and reliable endoscopic resection method for duodenal lesions. Issues related to gastric ESD were establishing an efficient traction method and a method to prevent post-ESD bleeding in high-risk patients. Other important issues were establishment of an efficient traction method and methods of preventing delayed bleeding in high-risk patients who undergo gastric ESD, expansion of indications for minimally invasive treatment using LECS for gastric cancer, the development of endoscopic full-thickness resection (EFTR) for gastric submucosal tumors (SMTs), and improvement of per-oral endoscopic myotomy (POEM) for esophageal achalasia and per-oral endoscopic tumor resection (POET) for esophageal SMTs. Through the JGES Core Sessions, it is expected that the minimally invasive treatments using endoscopes developed in Japan will be further advanced.

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.

Feasibility study comparing underwater endoscopic mucosal resection and conventional endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumor < 20 mm

BACKGROUND AND AIM

Underwater endoscopic mucosal resection (UEMR) has been reported as an alternative to conventional EMR for superficial non-ampullary duodenal epithelial tumors (SNADET). However, the detailed outcomes are unclear. This study aimed to compare the clinical outcomes between UEMR and EMR for SNADET <20 mm.

PATIENTS AND METHODS

This is a retrospective observational study using a prospective maintained database. From November 2017 to December 2018, 104 consecutive cases of attempted UEMR for SNADET <20 mm were prospectively allocated. A total of 240 cases of attempted EMR were chosen as historical controls. We compared technical success rate, defined as the resection rate without conversion to ESD; en bloc resection rate; R0 resection rate; and adverse event rate. Next, multivariate analyses were constructed to identify predictors of conversion to ESD, piecemeal resection, and RX or R1 (RX/R1) resection.

RESULTS

Technical success rate of UEMR was significantly higher than that of EMR (87% and 70%, P < 0.01). En bloc resection and R0 resection rates of UEMR were significantly lower than those of EMR (en bloc resection: 87% vs 96%, P < 0.01; R0 resection: 67% vs 80%, P = 0.05). Concerning adverse events, there were no significant differences. In multivariate analyses, attempted EMR, lesion size and depressed type were independent predictors of conversion to ESD. Attempted UEMR was an independent predictor of piecemeal resection and RX/R1 resection.

CONCLUSION

The present study indicated that UEMR could be a feasible endoscopic resection method for SNADET (UMIN000025442).

Evaluating the ACS-NSQIP Risk Calculator in Primary GI Neuroendocrine Tumor: Results from the United States Neuroendocrine Tumor Study Group

The ACS established an online risk calculator to help surgeons make patient-specific estimates of postoperative morbidity and mortality. Our objective was to assess the accuracy of the ACS-NSQIP calculator for estimating risk after curative intent resection for primary GI neuroendocrine tumors (GI-NETs). Adult patients with GI-NET who underwent complete resection from 2000 to 2017 were identified using a multi-institutional database, including data from eight academic medical centers. The ability of the NSQIP calculator to accurately predict a particular outcome was assessed using receiver operating characteristic curves and the area under the curve (AUC). Seven hundred three patients were identified who met inclusion criteria. The most commonly performed procedures were resection of the small intestine with anastomosis (N = 193, 26%) and partial colectomy with anastomosis (N = 136, 18%). The majority of patients were younger than 65 years (N = 482, 37%) and ASA Class III (N = 337, 48%). The most common comorbidities were diabetes (N = 128, 18%) and hypertension (N = 395, 56%). Complications among these patients based on ACS NSQIP definitions included any complication (N = 132, 19%), serious complication (N = 118, 17%), pneumonia (N = 7, 1.0%), cardiac complication (N = 1, 0.01%), SSI (N = 80, 11.4%), UTI (N = 17, 2.4%), venous thromboembolism (N = 18, 2.5%), renal failure (N = 16, 2.3%), return to the operating room (N = 27, 3.8%), discharge to nursing/rehabilitation (N = 22, 3.1%), and 30-day mortality (N = 9, 1.3%). The calculator provided reasonable estimates of risk for pneumonia (AUC = 0.721), cardiac complication (AUC = 0.773), UTI (AUC = 0.716), and discharge to nursing/ rehabilitation (AUC = 0.779) and performed poorly (AUC < 0.7) for all other complications Fig. 1). The ACS-NSQIP risk calculator estimates a similar proportion of risk to actual events in patients with GI-NET but has low specificity for identifying the correct patients for many types of complications. The risk calculator may require modification for some patient populations.

Management of perforation related to endoscopic submucosal dissection for superficial duodenal epithelial tumors

BACKGROUND AND AIMS

Endoscopic 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.

METHODS

Patients who underwent ESD for SDETs from July 2010 to December 2018 were studied. We collected data on complete closure, insertion of endoscopic nasobiliary and pancreatic duct drainage (ENBPD) tubes, and additional interventions. We also evaluated clinical outcomes, including the fasting period, hospital stay, and maximum serum C-reactive protein level.

RESULTS

ESD was completed in 264 patients with SDETs. Perforation was observed in 36 patients, including 4 patients with delayed perforation. Among 32 patients with intraoperative perforation, complete closure was achieved in 13 patients. Compared with patients without complete closure, the fasting period and hospital stay were significantly shorter and the maximum serum C-reactive protein level was significantly lower in patients with complete closure, which were equivalent to those in patients without perforation. In patients without complete closure for mucosal defect, no additional interventions were required when an ENBPD tube was inserted, whereas 2 patients without ENBPD tube insertion underwent additional interventions such as percutaneous drainage and a surgical operation.

CONCLUSIONS

Perforation associated with ESD for SDETs required complex conservative management with complete closure or insertion of an ENBPD tube.

Short- and long-term outcomes of endoscopic submucosal dissection for non-ampullary duodenal neuroendocrine tumors

Background

Endoscopic resection is recommended for non-ampullary duodenal neuroendocrine tumors (NAD-NETs) ≤10 mm in diameter and confined to the submucosal layer, without lymph node or distant metastasis. However, the efficacy and safety of endoscopic submucosal dissection (ESD) for NAD-NET remains unclear. The aim of this study was to assess the short-term efficacy and safety and the long-term outcomes of ESD for NAD-NET.

Methods

Eight patients with 8 NAD-NETs who underwent ESD between 2015 and 2018 were included. The indications for ESD were: i) tumor ≤10 mm in diameter; ii) NET G1; iii) confined to the submucosal layer; and iv) without lymph node or distant metastasis. We retrospectively assessed the short- and long-term outcomes and safety.

Results

The median patient age was 69 (48-76) years. All tumors were located in the duodenal bulb and showed 0-Is morphology. The median size was 6.4 (3-9.3) mm. The rates of en bloc resection, histologically free horizontal and vertical margins, and curative resection were 100%, 88%, and 88%, respectively. Intraoperative and postoperative perforation each occurred in 13% of patients, all of whom were treated conservatively and avoided emergent surgery. Delayed bleeding was not observed. No local, lymph node or distant recurrence was observed during a median follow-up period of 34 (18.5-62.5) months.

Conclusions

The rates of en bloc and curative resection, and histologically free margins were sufficiently high. Although intraoperative and postoperative perforations occurred, emergency surgery was not needed. The results show that ESD is an efficacious and safe treatment for NAD-NET.

Present Status of Endoscopic Submucosal Dissection for Non-Ampullary Duodenal Epithelial Tumors

Prediction of histology by endoscopic examination is important in the clinical management of non-ampullary duodenal epithelial tumors (NADETs), including adenoma and adenocarcinoma. The use of a simple scoring system based on the findings of white-light endoscopy or magnified endoscopy with narrow-band imaging is useful to differentiate between Vienna category 3 (C3) and C4/5 lesions. Less invasive endoscopic resection procedures, such as cold snare polypectomy, are quick to perform and convenient for small (<10 mm) C3 lesions. Neoplasms with higher grade histology, such as C4/5 lesions, should be treated by endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), or surgery. Although EMR often requires piecemeal resection, the complication rate is acceptable. Excellent complete resection rates could be achieved by ESD; however, it remains a challenging method considering the high risk of complications. Shielding or closure of the ulcer after ESD is effective at decreasing the risk of delayed bleeding and perforation. Laparoscopic endoscopic cooperative surgery is an ideal treatment with a high rate of en bloc resection and a low rate of complications, although it is limited to high-volume centers. Patients with NADETs could benefit from a multidisciplinary approach to stratify the optimal treatment based on endoscopic diagnoses.

Impact of electrical pulse cut mode during endoscopic papillectomy: Pilot randomized clinical trial

OBJECTIVE

Endoscopic papillectomy is increasingly being used for ampullary adenoma treatment. However, it remains challenging despite increased safety with treatment advances. The ideal power output and electrosurgical current mode for mucosal resection are not established. We aimed to identify the ideal electrical pulse for use during resection.

METHODS

This pilot randomized, single-blind, prospective, multicenter trial, recruited patients with ampullary adenomas and conventional anatomy who were scheduled to undergo endoscopic papillectomy. Endoscopic treatment was performed using a standardized algorithm and patients were randomized for endoscopic papillectomy with Endocut or Autocut. The primary outcome was the incidence of delayed bleeding. Incidence of procedure-related pancreatitis, successful complete resection, pathological findings, and other adverse events were secondary endpoints.

RESULTS

Sixty patients were enrolled over a 2-year period. The incidences of delayed bleeding (13.3% vs. 16.7%, P = 1.00) and pancreatitis (27% vs. 30%, P = 0.77) were similar between both groups. The rate of crush artifacts was higher in the Endocut than in the Autocut group (27% vs. 3.3%, P = 0.03). Immediate bleeding when resecting tumors greater than 14 mm in diameter was more common in the Autocut than in the Endocut group (88% vs. 46%, P = 0.04).

CONCLUSIONS

The Autocut and Endocut modes have similar efficacy and safety for endoscopic papillectomy. The Endocut mode may prevent immediate bleeding in cases with large tumor sizes, although it causes more frequent crush artifacts.

REGISTRY AND THE REGISTRATION NUMBER

The Japanese UMIN Clinical Trials Registry (UMIN-CTR: 000021382).

[Duodenal neuroendocrine tumors]

Significant augmentation of the incidence of duodenal neuroendocrine tumors duodenum has been observed in recent decades. There are 5 histological types of these tumors: gastrinoma (50-60%), somatostatin-producing tumor (15%), inactive serotonin-containing tumors (20%), poorly differentiated neuroendocrine carcinoma (<3%) and gangliocytic paraganglioma (<2%). The majority of tumors are localized within the bulb and postbulbar part of duodenum, 20% are found in periampular area. Treatment strategy depends on dimensions, localization, histological class, stage and type of tumor. It is believed that endoscopic resection is permissible for small inactive tumors (G1) located above major duodenal papilla. The majority of other neoplasms requires surgical resection. Personal experience of various surgeons is limited by small group of patients. Therefore, it is necessary to summarize results for selection of optimal treatment.

Endoscopic diagnosis and treatment of superficial non-ampullary 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 high-grade 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.

Clinicopathological features of superficial non-ampurally duodenal epithelial tumor; gastric phenotype of histology correlates to higher malignant potency

BACKGROUND

Superficial non-ampullary duodenal epithelial tumors (SNADETs) are relatively rare, but they are now being detected more frequently due to advances in endoscopic technology. Nevertheless, the pathological nature of SNADETs remains unclear and a management strategy for these tumors has not been established.

METHODS

To elucidate the clinicopathological features, we conducted a retrospective analysis of 138 endoscopically resected SNADETs. Lesions were classified into two groups by histological grade according to the Vienna classification: category 3 (71 lesions, 51.4%) and category 4/5 (67 lesions, 48.6%).

RESULTS

Compared with category 3 lesions, category 4/5 lesions were significantly more common in elderly patients (p < 0.001) and had a significantly larger tumor diameter (p = 0.001). Immunohistochemical analysis showed that category 4/5 lesions expressed MUC5AC (p = 0.002), MUC6 (p < 0.001), and p53 (p = 0.003) significantly more frequently and expressed CD10 (p = 0.002) and CDX2 (p = 0.029) significantly less frequently. Multivariate regression analysis showed that advanced age (p < 0.001), MUC6 expression (p = 0.001), and p53 expression (p = 0.004) were independent risk factors for a classification of category 4/5. In addition, advanced age (p = 0.010) and MUC5AC expression (p = 0.011) were identified as risk factors for lesions classified as category 4.2 (noninvasive carcinoma) or higher. All category 5 lesions expressed MUC5AC.

CONCLUSIONS

The gastric phenotype of MUC5AC and MUC6 may be linked to the malignant potential of SNADETs.

Endoscopic closure after intraluminal surgery

Endoscopic submucosal dissection is established as a curative endoscopic method for gastrointestinal epithelial neoplasms with a high possibility of complete en bloc resection; however, postoperative adverse events of bleeding and delayed perforation remain. To prevent or minimize them, several techniques for endoscopic mucosal closure have been introduced, such as using endoscopic clips, combined use of hemoclips and supplement devices, and specially designed endoscopic suturing devices. Furthermore, endoscopic full-thickness suturing technique for gastrointestinal wall defect has been developed based on the concept in natural orifice transluminal endoscopic surgery and endoscopic full-thickness resection. Several closure techniques, including over-the-scope clip, threaded bars inserted in a hollow needle, stitches or staplers, and a curved needle and thread are reported. Secure closure of the iatrogenic defect may further expand the range of therapeutic endoscopy. Accumulation of evidence for the efficacy of endoscopic closure and establishment of these techniques are desired.

Endoscopic submucosal dissection for duodenal tumors

Recently, endoscopic submucosal dissection (ESD) for the duodenal tumors has come to be treated in many institutions, but has also showed many problems of feasibility and safety compared with endoscopic mucosal resection (EMR). Although duodenal ESD is expected to be more effective for the prevention of postoperative local recurrence, high incidence rate of duodenal perforation and emergency surgical rescue are big problem. Prophylactic mucosal closure by clipping device, polyglycolic acid sheets shielding, and the laparoscopic and endoscopic cooperative surgery are reported to be effective measures to overwhelm the various problems associated with duodenal ESD. However, duodenal ESD still has quite a bit of room for improvement of the procedure, and currently the indication should be well discussed before treatment in consideration of the expected therapeutic effect and complications.