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Abstract
INTRODUCTION Although sporadic non-ampullary duodenal adenomas (SNADA) are rare, with the risk of progression to cancer, they deserve therapy. Endoscopic therapy of SNADA is effective, but with the increased risk of complications, endotherapy should be performed in high-volume units. The results of endotherapy of SNADA in our unit are presented. PATIENTS AND METHODS A total of 97 patients with SNADA had endoscopic resection in 2005-2021 and control endoscopies between 3 and 24 months. Snare polypectomy, endoscopic mucosal resection (EMR), endoscopic band ligation (EBL) and endoloop were used (en bloc 37% and piecemeal 63%). In cases of residual/recurrent adenomas, endotherapy was repeated. RESULTS The median size of the adenoma was 12 (5-60) mm and most polyps were sessile (25%) or flat (65%). Primary endotherapy eradicated adenomas in 57 (59%) cases. Residual and recurrence rates were 24% (n = 23) and 17% (n = 16) with successful endotherapy in 16 (70%) and 13 (81%) patients. Endotherapy was successful in 86 (89%) patients after a median (range) follow-up of 23 (1-166) months. Four out of 11 patients with failed endotherapy had surgery; seven patients were not fit for surgery. There were no disease-specific deaths or carcinoma. Eleven patients (11%) suffered from complications: perforation requiring surgery (n = 1), sepsis (n = 1), postprocedure bleeding (n = 7), cardiac arrest (n = 1) and coronary infarct (n = 1). The thirty-day mortality was zero. Colonoscopy was performed on 67 (69%) patients with neoplastic lesions in 33% patients during follow-up. CONCLUSIONS Endotherapy of SNADA is effective and safe. Repeat endotherapy in residual and recurrent adenomas is successful. Careful patient selection is mandatory. Abbreviations: ASA: American Society of Anesthesiologist classification; BMI: body mass index; CT: computed tomography; EBL: endoscopic band ligation; EMR: endoscopic mucosal resection; ESD: endoscopic submucosal dissection; ET: endotherapy; FAP: familial adenomatous polyposis; F: female; LST: laterally spreading tumours; M: male; SD: standard deviation; SNADA: sporadic nonampullary duodenal adenoma.
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Affiliation(s)
- Marianne Udd
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Outi Lindström
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Andrea Tenca
- Gastroenterology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mia Rainio
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Leena Kylänpää
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Aso N, Ohtsuka K, Shibahara J, Koda H, Morikawa T, Abe N, Watanabe T, Ohnishi H. Microsatellite instability in the high-grade dysplasia component of duodenal adenoma is associated with progression to adenocarcinoma. Surg Today 2023; 53:252-260. [PMID: 35871406 DOI: 10.1007/s00595-022-02558-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/26/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE We examined the microsatellite instability of duodenal tumors to evaluate their molecular features associated with the adenoma-carcinoma sequence. METHODS Fifty-two non-ampullary duodenal epithelial tumors collected by endoscopic mucosal resection or surgical resection were studied. When a tumor had two or more dysplasia grades, the highest grade was considered. Representative areas were macro-dissected and subjected to a microsatellite instability analysis and immunohistochemical staining. RESULTS The 52 tumors were classified as either adenoma with low-grade dysplasia (n = 18), adenoma with high-grade dysplasia (n = 20), or adenocarcinomas (n = 14). Among these, 3 adenocarcinoma cases showed microsatellite instability and the remaining 49 tumors showed microsatellite stability. Of the 14 adenocarcinoma cases, 3 contained both high-grade dysplasia and adenocarcinoma components, and 11 contained only the adenocarcinoma component. Interestingly, all three adenocarcinoma + high-grade dysplasia cases were microsatellite instability-high in both the adenocarcinoma and high-grade dysplasia components. Immunohistochemical staining of mismatch repair proteins showed mismatch repair deficiency in three microsatellite instability-high adenocarcinoma + high-grade dysplasia cases. CONCLUSIONS Only adenocarcinoma cases with high-grade dysplasia components were microsatellite instability-high (in both the adenocarcinoma and high-grade dysplasia components). This suggests that microsatellite instability in the high-grade dysplasia component of duodenal adenoma is associated with progression to adenocarcinoma.
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Affiliation(s)
- Nobuyoshi Aso
- Department of Gastroenterological and General Surgery, Faculty of Medicine, Kyorin University, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan.
| | - Kouki Ohtsuka
- Department of Laboratory Medicine, Faculty of Medicine, Kyorin University, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Junji Shibahara
- Department of Pathology, Faculty of Medicine, Kyorin University, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Hirotomo Koda
- Department of Pathology, NTT Medical Center Tokyo, 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, 141-8625, Japan
| | - Teppei Morikawa
- Department of Pathology, NTT Medical Center Tokyo, 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, 141-8625, Japan
| | - Nobutsugu Abe
- Department of Gastroenterological and General Surgery, Faculty of Medicine, Kyorin University, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Takashi Watanabe
- Department of Laboratory Medicine, Faculty of Medicine, Kyorin University, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Hiroaki Ohnishi
- Department of Laboratory Medicine, Faculty of Medicine, Kyorin University, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
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Woo SM, Real MJ, Will BM, Kim EJ, Chou J, Alsaiari AA, Nakshabandi A, Chalhoub WM, Haddad NG. Clinical outcomes: endoscopic resection of duodenal ampullary lesions. Transl Gastroenterol Hepatol 2023; 8:15. [PMID: 37197254 PMCID: PMC10184035 DOI: 10.21037/tgh-22-87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/01/2023] [Indexed: 05/19/2023] Open
Abstract
Background Ampullary adenomas are lesions at the duodenum's major papilla commonly associated with familial adenomatous polyposis (FAP) but may also occur sporadically. Historically, ampullary adenomas were removed surgically, however endoscopic resection has become the preferred method of resection. Most of the literature on management of ampullary adenomas are small single-center retrospective reviews. The objective of this study is to describe endoscopic papillectomy outcomes to further refine management guidelines. Methods This is a retrospective study of patients who underwent endoscopic papillectomy. Demographic data were included. Details regarding lesions and procedures were also collected, including endoscopic impression, size, resection method and adjunctive therapies. Chi-square, Kruskal-Wallis rank-sum, and t-tests were performed. Results A total of 90 patients were included. 60% patients (54 of 90) had pathology-proven adenomas. 14.4% of all lesions (13 of 90) and 18.5% of adenomas (10 of 54) were treated with APC. Among APC-treated lesions, 36.4% developed recurrence (4 of 11) vs. 7.1% developed residual lesion (1 of 14) (P=0.019). 15.6% of all lesions (14 of 90) and 18.5% of adenomas (10 of 54) reported complications, and the most common was pancreatitis (11.1% and 5.6%). Median follow-up time was 8 months for all lesions and 14 months (range, 1-177 months) for adenomas, with time to recurrence 30 and 31 months (range, 1-137 months), respectively. Recurrence was observed in 16.7% of all lesions (15 of 90) and 20.4% of adenomas (11 of 54). Endoscopic success was observed in 69.2% of all lesions (54 of 78) and 71.4% of adenomas (35 of 49) after removing patients lost to follow-up. Conclusions Endoscopic papillectomy is an effective method for managing duodenal adenomas. Pathology-proven adenoma should undergo surveillance for at least 31 months. Lesions treated with APC may require closer follow-up and for a prolonged period.
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Affiliation(s)
- Stephanie M. Woo
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Mark J. Real
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Brett M. Will
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
- Georgetown University School of Medicine, Washington, DC, USA
| | - Eric J. Kim
- Georgetown University School of Medicine, Washington, DC, USA
- Department of Anesthesiology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jiling Chou
- MedStar Health Research Institute, Hyattsville, MD, USA
| | - Ahmed A. Alsaiari
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Internal Medicine, Jeddah University, Jeddah, Saudi Arabia
| | - Ahmad Nakshabandi
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Gastroenterology, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Walid M. Chalhoub
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Nadim G. Haddad
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC, USA
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Miwa T, Yamada S, Shibuya K, Hirano K, Takami H, Watanabe T, Hayashi M, Yoshioka I, Kodera Y, Fujii T. Clip-guided local duodenectomy for safe and minimal local resection of nonampullary duodenal neoplasms. BMC Surg 2022; 22:328. [PMID: 36038851 PMCID: PMC9422168 DOI: 10.1186/s12893-022-01771-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 08/16/2022] [Indexed: 11/23/2022] Open
Abstract
Background Local duodenectomy and primary closure is a simple option for some nonampullary duodenal neoplasms. Minimizing the resection area while ensuring curability is necessary for safe primary duodenal closure. However, it is often difficult to determine the appropriate resection line from the serosal side. We developed clip-guided local duodenectomy to easily determine the resection range and perform local duodenectomy safely, then performed a retrospective observational study to confirm the safety of clip-guided local duodenectomy. Methods The procedure is as follows: placing endoscopic metal clips at four points on the margin around the tumor within 3 days before surgery, identifying the tumor extent with the clips under X-ray imaging during surgery, making an incision to the duodenum just outside of the clips visualized by X-ray imaging, full-thickness resection of the duodenum with the clips as guides of tumor demarcation, and transversely closure by Gambee suture. We evaluated clinicopathological data and surgical outcomes of patients who underwent clip-guided local duodenectomy at two surgical centers between January 2010 and May 2020. Results Eighteen patients were included. The pathological diagnosis was adenoma (11 cases), adenocarcinoma (6 cases), and GIST (1 case). The mean ± SD tumor size was 18 ± 6 mm, and the tumor was mainly located in the second portion of the duodenum (66%). In all cases, the duodenal defect was closed with primary sutures. The mean operation time and blood loss were 191 min and 79 mL, respectively. The morbidity was 22%, and all complications were Clavien–Dindo grade II. No anastomotic leakage or stenosis was observed. In the 6 adenocarcinoma patients, all were diagnosed with pT1a, and postoperative recurrence was not observed. The 1-year overall and recurrence free survival rate was 100%. Conclusions Clip-guided local duodenectomy is a safe and useful surgical option for minimally local resection of nonampullary duodenal neoplasms such as duodenal adenoma, GIST, and early adenocarcinoma.
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Affiliation(s)
- Takeshi Miwa
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Suguru Yamada
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuto Shibuya
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Katsuhisa Hirano
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Hideki Takami
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toru Watanabe
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Masamichi Hayashi
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Isaku Yoshioka
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan.
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Okubo T, Ogawa R, Ueno S, Ito S, Hayakawa S, Sagawa H, Tanaka T, Takahashi H, Matsuo Y, Shimura T, Kataoka H, Takiguchi S. ESD-aid surgery as a new treatment strategy for duodenal adenoma. BMC Res Notes 2022; 15:33. [PMID: 35144663 PMCID: PMC8830093 DOI: 10.1186/s13104-022-05922-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/25/2022] [Indexed: 11/21/2022] Open
Abstract
Objective The treatment for nonampullary duodenal adenoma remains to have no consensus and established methods. Although endoscopic treatment is minimally invasive, it was reported to cause delayed perforation in more than 20% of cases. For adenomas in the duodenum, we performed endoscopic submucosal dissection (ESD)-aid surgery, which is a procedure to prophylactically suture the seromuscular structure of the duodenum after ESD. In this procedure, we did not perform Kocher mobilization prior to ESD to facilitate endoscopic resection and full-thickness resection to prevent spread of the tumor and infection to the abdominal cavity. The duodenal wall was reinforced in planes using a suture clip. Results Of the 13 cases of duodenal adenoma that underwent ESD-aid surgery at our hospital between April 2018 and December 2020, 1 developed postoperative bleeding, but there was no late perforation. For duodenal adenomas, ESD-aid surgery was considered a safe and minimally invasive treatment.
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Affiliation(s)
- Tomotaka Okubo
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Ryo Ogawa
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan.
| | - Shuhei Ueno
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Sunao Ito
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Shunsuke Hayakawa
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Hiroyuki Sagawa
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Tatsuya Tanaka
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Hiroki Takahashi
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Yoichi Matsuo
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Takaya Shimura
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Hiromi Kataoka
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Shuji Takiguchi
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
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Santos-Antunes J, Morais R, Marques M, Macedo G. Underwater Duodenal ESD of a Large Adenoma Using the Pocket-Creation Method. GE Port J Gastroenterol 2021; 28:367-369. [PMID: 34604470 DOI: 10.1159/000512360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 09/17/2020] [Indexed: 11/19/2022]
Affiliation(s)
- João Santos-Antunes
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar S. João, Porto, Portugal.,i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal.,IPATIMUP - Institute of Molecular Pathology and Immunology, University of Porto, Porto, Portugal
| | - Rui Morais
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar S. João, Porto, Portugal
| | - Margarida Marques
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar S. João, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Faculty of Medicine, Centro Hospitalar S. João, Porto, Portugal
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Dong T, Wang L, Zhao L, Fan Z. Synchronous duodenal and colonic advanced adenomas during post-colorectal cancer surveillance. Dig Liver Dis 2021; 53:915-916. [PMID: 32713787 DOI: 10.1016/j.dld.2020.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/02/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Tao Dong
- Department of Digestive Endoscopy, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China; Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lan Wang
- Department of Digestive Endoscopy, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China; Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lili Zhao
- Department of Digestive Endoscopy, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China; Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Zhining Fan
- Department of Digestive Endoscopy, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China; Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China.
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8
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Kumar S, Harminder Bhogal R. Localised duodenal and proximal jejunal resections. Am J Surg 2021; 222:1193-1195. [PMID: 34030869 DOI: 10.1016/j.amjsurg.2021.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/26/2021] [Accepted: 04/30/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Sacheen Kumar
- Department of Surgery, The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, United Kingdom; Institute of Cancer Research, 123 Old Brompton Road, London, SW7 3RP, United Kingdom
| | - Ricky Harminder Bhogal
- Department of Surgery, The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, United Kingdom; Institute of Cancer Research, 123 Old Brompton Road, London, SW7 3RP, United Kingdom.
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Naples R, Simon R, Moslim M, Augustin T, Church J, Burke CA, Bhatt A, Kalady M, Walsh RM. Long-Term Outcomes of Pancreas-Sparing Duodenectomy for Duodenal Polyposis in Familial Adenomatous Polyposis Syndrome. J Gastrointest Surg 2021; 25:1233-1240. [PMID: 32410179 DOI: 10.1007/s11605-020-04621-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/19/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreas-sparing duodenectomy (PSD) offers definitive therapy for duodenal polyposis associated with familial adenomatous polyposis (FAP). We reviewed the long-term complications of PSD and evaluated the incidence of high-grade dysplasia (HGD) and cancer in the remaining upper gastrointestinal tract. METHODS Forty-seven FAP patients with duodenal polyposis undergoing PSD from 1992 to 2019 were reviewed. Long-term was defined as > 30 days from PSD. RESULTS All patients were treated with an open technique, and 43 (91.5%) had Spigelman stage III or IV duodenal polyposis. Median follow-up was 107 months (IQR, 26-147). There was no 90-day mortality. Seven patients died at a median of 10.5 years (IQR, 5.4-13.3) after PSD, with one attributed to gastric cancer. Pancreatitis occurred in 10 patients (21.3%), and two required surgical intervention. Seven patients (14.9%) developed an incisional hernia, and all underwent definitive repair. Forty-one patients (87.2%) had postoperative surveillance endoscopy over a median follow-up of 111 months (IQR, 42-138). Three patients (6.4%) developed adenocarcinoma (two gastric, one jejunal), and four (8.5%) had adenomas with HGD (two gastric, two jejunal) with a median of 15 years (IQR, 9-16) from PSD. One patient with gastric adenocarcinoma and all patients with HGD or adenocarcinoma of the jejunum required surgical intervention. CONCLUSION PSD can be performed with a low but definable risk of long-term morbidity. Risk of gastric and jejunal carcinoma rarely occurs and was diagnosed decades after PSD. This demonstrates the need for lifelong endoscopic surveillance and educates us on the risk of carcinoma in the remaining gastrointestinal tract.
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Affiliation(s)
- Robert Naples
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, Cleveland, OH, 44195, USA
| | - Robert Simon
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, Cleveland, OH, 44195, USA.
| | - Maitham Moslim
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, Cleveland, OH, 44195, USA
| | - Toms Augustin
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, Cleveland, OH, 44195, USA
| | - James Church
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA.,Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA
| | - Carol A Burke
- Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA.,Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Amit Bhatt
- Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA.,Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Kalady
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA.,Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA
| | - R Matthew Walsh
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, Cleveland, OH, 44195, USA.,Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA
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10
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Noh JH, Song EM, Ahn JY, Yang DH, Lee W, Hong J, Kim A, Na HK, Lee JH, Jung KW, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY. Prevalence and endoscopic treatment outcomes of upper gastrointestinal neoplasms in familial adenomatous polyposis. Surg Endosc 2021; 36:1310-1319. [PMID: 33709227 DOI: 10.1007/s00464-021-08406-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although upper gastrointestinal (GI) neoplasms are not rare in patients with familial adenomatous polyposis (FAP), few studies have focused on them and the long-term outcomes of their treatment by endoscopy. Therefore, we aimed to investigate the prevalence and endoscopic treatment outcomes of upper GI neoplasms in patients with FAP. METHODS Among 215 patients diagnosed with FAP between January 1991 and December 2019, 208 who underwent esophagogastroduodenoscopy were eligible. The clinical features and endoscopic treatment outcomes of upper GI neoplasms were retrospectively investigated and analyzed. RESULTS Among the enrolled patients, 113 (54.3%) had one or more upper GI neoplasms: gastric adenoma (n = 34), gastric cancer (n = 7), nonampullary duodenal adenoma (n = 86), and ampullary adenoma (n = 53). Among patients with gastric neoplasms (n = 37), 24 (64.9%) underwent treatment (endoscopic treatment: 22, surgery: 2). No tumor-related mortality occurred during median follow-up of 106 months (interquartile range [IQR] 63-174). Endoscopic treatment was performed in 47 (54.7%) of 86 patients with nonampullary duodenal adenoma and in 32 (60.4%) of 53 patients with ampullary adenoma. No patient underwent surgery for duodenal neoplasms, and no tumor-related mortality occurred during median follow-up of 88 months (IQR 42-145). The proportion of patients with increased Spigelman stage at 2 years after the initial diagnosis or treatment was significantly higher in untreated group than in the group treated for duodenal neoplasms (27.3% vs. 0.0%, p = 0.001). CONCLUSION Endoscopic surveillance in FAP patients is important for the detection and treatment of upper GI neoplasms in early stage. In particular, endoscopic therapy for duodenal neoplasms can reduce the severity of duodenal polyposis.
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Affiliation(s)
- Jin Hee Noh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Mi Song
- Department of Gastroenterology, Ewha Womans University Medical Center, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Woochang Lee
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jinyoung Hong
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Aram Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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11
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Chung J, Wang K, Podboy A, Gaddam S, K Lo S. Endoscopic Suturing for the Prevention and Treatment of Complications Associated with Endoscopic Mucosal Resection of Large Duodenal Adenomas. Clin Endosc 2021; 55:95-100. [PMID: 33652516 PMCID: PMC8831414 DOI: 10.5946/ce.2020.281] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/07/2020] [Indexed: 12/15/2022] Open
Abstract
Background/Aims Endoscopic mucosal resection (EMR) is the primary treatment for duodenal adenomas; however, it is associated with a high risk of perforation and bleeding, especially with larger lesions. The goal of this study was to demonstrate the feasibility and safety of endoscopic suturing (ES) for the closure of mucosal defects after duodenal EMR.
Methods Consecutive adult patients who underwent ES of large mucosal defects after EMR of large (>2 cm) duodenal adenomas were retrospectively enrolled. The OverStitch ES system was employed for closing mucosal defects after EMR. Clinical outcomes and complications, including delayed bleeding and perforation, were documented.
Results During the study period, ES of mucosal defects was performed in seven patients in eight sessions (six for prophylaxis and two for the treatment of perforation). All ES sessions were technically successful. No early or delayed post-EMR bleeding was recorded. In addition, no clinically obvious duodenal stricture or recurrence was encountered on endoscopic follow-up evaluation, and no patients required subsequent surgical intervention.
Conclusions ES for the prevention and treatment of duodenal perforation after EMR is technically feasible, safe, and effective. ES should be considered an option for preventing or treating perforations associated with EMR of large duodenal adenomas.
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Affiliation(s)
- Jaeil Chung
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kelly Wang
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alexander Podboy
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Srinivas Gaddam
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Simon K Lo
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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12
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Hoibian S, Ratone JP, Gonzalez JM, Bories E, Pesenti C, Caillol F, Grimaud JC, Giovannini M, Barthet M. Endoscopic mucosal resection of sporadic duodenal nonampullary adenoma: outcomes of 130 patients with a long-term follow up in two tertiary French centers. Ann Gastroenterol 2021; 34:169-176. [PMID: 33654355 PMCID: PMC7903584 DOI: 10.20524/aog.2021.0581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/23/2020] [Indexed: 11/11/2022] Open
Abstract
Background The long-term outcomes and safety of endoscopic mucosal resection (EMR) of sporadic duodenal adenoma (SDA), and the management of adverse events need to be confirmed. Methods A bicentric retrospective study was performed including all patients who underwent EMR for SDAs from 2003-2016. The primary aim was to evaluate the efficiency of EMR for SDA. The secondary objectives were to assess safety, recurrence management, predictive factors for treatment success, and adverse events. Results One hundred thirty patients (134 procedures) were included (median age 65 years, 49.3% male). The mean SDA size was 20.7 (range 5-50) mm. Of the SDAs, 58.2% were category 3 of the Vienna classification, 35.8% were category 4, and 5.9% were category 5. The median follow up was 25.0 (range 2-120) months. Complete mucosal resection was achieved for 129/134 lesions (96.2%), with en bloc resection in 59/134 (44%). Recurrence occurred in 28.6% of cases (30/105 procedures). Recurrence was successfully treated by new endoscopic procedures in 72.2% (13/18) and by surgery in 27.8% (5/18). Delayed bleeding occurred in 13.4% of cases (18/134) and was successfully managed endoscopically. The perforation rate was 3.7% (5/134); perforations were managed without surgery in 60% (3/5 patients) of cases. Conclusions Endoscopic treatment of SDA appears to be effective and relatively safe in tertiary centers. All bleeding complications were endoscopically controlled, and perforation was rare. Recurrence was frequent but could be managed endoscopically. EMR is confirmed as a first-line treatment in cases of SDA, and surgery is useful only if repeated EMRs fail.
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Affiliation(s)
- Solène Hoibian
- Gastroenterology Unit, Hôpitaux Universitaires de Marseille Nord, Chemin des Bourrely (Solène Hoibian, Jean-Michel Gonzalez, Jean-Charles Grimaud, Marc Barthet).,Endoscopy Unit, Paoli-Calmettes Institute (Solène Hoibian, Jean-Philippe Ratone, Jean-Michel Gonzaleza Erwan Bories, Christian Pesenti, Fabrice Caillol, Marc Giovannini), Marseille, France
| | - Jean-Philippe Ratone
- Endoscopy Unit, Paoli-Calmettes Institute (Solène Hoibian, Jean-Philippe Ratone, Jean-Michel Gonzaleza Erwan Bories, Christian Pesenti, Fabrice Caillol, Marc Giovannini), Marseille, France
| | - Jean-Michel Gonzalez
- Gastroenterology Unit, Hôpitaux Universitaires de Marseille Nord, Chemin des Bourrely (Solène Hoibian, Jean-Michel Gonzalez, Jean-Charles Grimaud, Marc Barthet)
| | - Erwan Bories
- Endoscopy Unit, Paoli-Calmettes Institute (Solène Hoibian, Jean-Philippe Ratone, Jean-Michel Gonzaleza Erwan Bories, Christian Pesenti, Fabrice Caillol, Marc Giovannini), Marseille, France
| | - Christian Pesenti
- Endoscopy Unit, Paoli-Calmettes Institute (Solène Hoibian, Jean-Philippe Ratone, Jean-Michel Gonzaleza Erwan Bories, Christian Pesenti, Fabrice Caillol, Marc Giovannini), Marseille, France
| | - Fabrice Caillol
- Endoscopy Unit, Paoli-Calmettes Institute (Solène Hoibian, Jean-Philippe Ratone, Jean-Michel Gonzaleza Erwan Bories, Christian Pesenti, Fabrice Caillol, Marc Giovannini), Marseille, France
| | - Jean-Charles Grimaud
- Gastroenterology Unit, Hôpitaux Universitaires de Marseille Nord, Chemin des Bourrely (Solène Hoibian, Jean-Michel Gonzalez, Jean-Charles Grimaud, Marc Barthet)
| | - Marc Giovannini
- Endoscopy Unit, Paoli-Calmettes Institute (Solène Hoibian, Jean-Philippe Ratone, Jean-Michel Gonzaleza Erwan Bories, Christian Pesenti, Fabrice Caillol, Marc Giovannini), Marseille, France
| | - Marc Barthet
- Gastroenterology Unit, Hôpitaux Universitaires de Marseille Nord, Chemin des Bourrely (Solène Hoibian, Jean-Michel Gonzalez, Jean-Charles Grimaud, Marc Barthet)
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13
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Li XY, Ji KY, Qu YH, Zheng JJ, Guo YJ, Zhang CP, Zhang KP. Application of endoscopic submucosal dissection in duodenal space-occupying lesions. World J Clin Cases 2020; 8:6296-6305. [PMID: 33392310 PMCID: PMC7760427 DOI: 10.12998/wjcc.v8.i24.6296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/15/2020] [Accepted: 09/25/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) has been advocated by digestive endoscopists because of its comparable therapeutic effect to surgery, reduced trauma, faster recovery, and fewer complications. However, ESD for lesions of the duodenum is more challenging than those occurring at other levels of the gastrointestinal tract due to the thin intestinal wall of the duodenum, narrow intestinal space, rich peripheral blood flow, proximity to vital organs, and high risks of critical adverse events including intraoperative and delayed bleeding and perforation. Because of the low prevalence of the disease and the high risks of severe adverse events, successful ESD for lesions of the duodenum has rarely been reported in recent years.
AIM To investigate the efficacy and safety of ESD in the treatment of duodenal space-occupying lesions.
METHODS Clinical data of 24 cases of duodenal lesions treated by ESD at the Digestive Endoscopy Center of the Affiliated Hospital of Qingdao University from January 2016 to December 2019 were retrospectively analyzed.
RESULTS All of the 24 cases from 23 patients underwent ESD treatment for duodenal space-occupying lesions under general anesthesia, including 15 male and 8 female patients, with a mean age of 58.5 (32.0-74.0) years. There were 12 lesions (50%) in the duodenal bulb, 9 (37.5%) in the descending part, and 3 (12.5%) in the ball-descending junction. The mean diameter of the lesion was 12.75 (range, 11-22) mm. Thirteen lesions originated from the mucosa, of which 4 were low-grade intraepithelial neoplasia, 3 were hyperplastic polyps, 2 were chronic mucositis, 2 were adenomatous hyperplasia, 1 was high-grade intraepithelial neoplasia, and 1 was tubular adenoma. Eleven lesions were in the submucosa, including 5 neuroendocrine neoplasms, 2 cases of ectopic pancreas, 1 stromal tumor, 1 leiomyoma, 1 submucosal duodenal adenoma, and 1 case of submucosal lymph follicular hyperplasia. The intraoperative perforation rate was 20.8% (5/24), including 4 submucosal protuberant lesions and 1 depressed lesion. The mean length of hospital stay was 5.7 (range, 3-10) d, and the average follow-up time was 25.8 (range, 3.0–50.0) mo. No residual disease or recurrence was found in all patients, and no complications, such as infection and stenosis, were found during the follow-up period.
CONCLUSION ESD is safe and effective in the treatment of duodenal lesions; however, the endoscopists should pay more attention to the preoperative preparation, intraoperative skills, and postoperative treatment.
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Affiliation(s)
- Xiao-Yu Li
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Kai-Yue Ji
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Yu-Hu Qu
- Endoscopy Center, Shandong Qingdao Sanatorium, Qingdao 266000, Shandong Province, China
| | - Juan-Juan Zheng
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Ying-Jie Guo
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Cui-Ping Zhang
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Kun-Peng Zhang
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
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14
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Kojima Y, Ohtsuka K, Ishii S, Aso N, Ohki A, Hashimoto Y, Takeuchi H, Ohnishi H, Abe N. STK11 p.F354L Germline Mutation in a Case of Multiple Gastrointestinal Tumors. Case Rep Gastroenterol 2020; 14:547-553. [PMID: 33250696 PMCID: PMC7670341 DOI: 10.1159/000508929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/19/2020] [Indexed: 12/22/2022] Open
Abstract
Serine/threonine kinase 11 (STK11) is known as a critical tumor-suppressor gene that is frequently mutated in a broad spectrum of human cancers. Among these, the p.F354L mutation of STK11 has been identified in sporadic colon or lung cancer cases. Here, we report the case of a 75-year-old male patient who underwent surgical treatment for multiple tumors of the gastrointestinal system. Genetic mutations were screened in all resected samples, including duodenal high-grade adenoma, gastric high-grade adenoma, rectal adenocarcinoma, and liver metastasis of rectal adenocarcinoma, by next-generation sequencing for mutational hotspots involving 50 oncogenes and tumor suppressor genes. The characteristic hamartomatous polyp of Peutz-Jeghers syndrome was not detected in any tumor specimen. However, all samples as well as the normal rectal mucosa harbored the genetic mutation p.F354L in STK11. In addition, somatic mutations coexisted in the tumor samples, including KRAS p.A146T, TP53 p.G238X, and APC p.T1556fs in the duodenal adenoma; TP53 p.G238Y and APC p.T1556fs in the gastric adenoma; and TP53 p.R282W in the rectal adenocarcinoma and metastatic liver cancer. No somatic mutation was detected in the normal rectal mucosa as a control sample. To our knowledge, this is the first report of an STK11 germline mutation in a patient with multiple tumors of the gastrointestinal tract.
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Affiliation(s)
- Yohei Kojima
- Department of Gastroenterological and General Surgery, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Kouki Ohtsuka
- Department of Laboratory Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Shun Ishii
- Department of Gastroenterological and General Surgery, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Nobuyoshi Aso
- Department of Gastroenterological and General Surgery, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Atsuko Ohki
- Department of Gastroenterological and General Surgery, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Yoshikazu Hashimoto
- Department of Gastroenterological and General Surgery, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Hirohisa Takeuchi
- Department of Gastroenterological and General Surgery, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Hiroaki Ohnishi
- Department of Laboratory Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Nobutsugu Abe
- Department of Gastroenterological and General Surgery, Kyorin University Faculty of Medicine, Tokyo, Japan
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15
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Akahoshi K, Kubokawa M, Inamura K, Akahoshi K, Shiratsuchi Y, Tamura S. Current Challenge: Endoscopic Submucosal Dissection of Superficial Non-ampullary Duodenal Epithelial Tumors. Curr Treat Options Oncol 2020; 21:98. [PMID: 33104938 PMCID: PMC7588384 DOI: 10.1007/s11864-020-00796-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Kazuya Akahoshi
- Endoscopy Center, Aso Iizuka Hospital, 3-83 Yoshio town, Iizuka, 820-8505, Japan.
- Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, 820-8505, Japan.
| | - Masaru Kubokawa
- Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, 820-8505, Japan
| | - Kazuki Inamura
- Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, 820-8505, Japan
| | - Kazuaki Akahoshi
- Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, 820-8505, Japan
| | - Yuki Shiratsuchi
- Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, 820-8505, Japan
| | - Shinichi Tamura
- Faculty of Medical Engineering, Aso Iizuka Hospital, Iizuka, 820-8505, Japan
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16
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Wang KP, Jiang H, Kong C, Wang LZ, Wang GY, Mo JG, Jin C. Adult duodenal intussusception with horizontal adenoma: A rare case report. World J Clin Cases 2020; 8:3314-3319. [PMID: 32874987 PMCID: PMC7441246 DOI: 10.12998/wjcc.v8.i15.3314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/01/2020] [Accepted: 07/14/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Adult duodenal intussusception rarely occurs, and the majority of duodenal adenomas are located in the descending part of the duodenum. Therefore, adenomas in the horizontal part of the duodenum presenting as duodenal intussusception in adults are extremely rare.
CASE SUMMARY A 36-year-old man complained of abdominal pain for 13 d. Blood analysis showed anemia. Magnetic resonance cholangiopancreatography and computed tomography revealed a tumor in the horizontal part of the duodenum as the main finding, leading to duodeno-duodenal intussusception. No obvious abnormalities were found on endoscopy or upper gastrointestinal radiography. He was diagnosed with duodenal intussusception secondary to duodenal adenoma. Laparotomy showed duodeno-duodenal intussusception and a tumor in the horizontal part of the duodenum near the ascending part. Postoperative pathology revealed tubular-villous adenoma with low-grade glandular intraepithelial neoplasia (local high-grade intraepithelial neoplasia). He was discharged without complications.
CONCLUSION This case highlights that rational use of computed tomography, magnetic resonance cholangiopancreatography, endoscopy and upper gastrointestinal radiography for preoperative diagnosis and timely surgery is an effective strategy for the treatment of adult duodenal intussusception with duodenal masses.
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Affiliation(s)
- Kun-Peng Wang
- Department of General Surgery, Taizhou Central Hospital (Taizhou University Hospital), Taizhou 318000, Zhejiang Province, China
| | - Hao Jiang
- Department of General Surgery, Taizhou Central Hospital (Taizhou University Hospital), Taizhou 318000, Zhejiang Province, China
| | - Can Kong
- Department of General Surgery, Taizhou Central Hospital (Taizhou University Hospital), Taizhou 318000, Zhejiang Province, China
| | - Lie-Zhi Wang
- Department of General Surgery, Taizhou Central Hospital (Taizhou University Hospital), Taizhou 318000, Zhejiang Province, China
| | - Guo-Yu Wang
- Department of Radiology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou 318000, Zhejiang Province, China
| | - Jing-Gang Mo
- Department of General Surgery, Taizhou Central Hospital (Taizhou University Hospital), Taizhou 318000, Zhejiang Province, China
| | - Chong Jin
- Department of General Surgery, Taizhou Central Hospital (Taizhou University Hospital), Taizhou 318000, Zhejiang Province, China
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Abstract
The ampulla of Vater gives rise to a versatile group of cancers of mixed/hybrid histologic phenotype. Ampullary carcinomas (ACs) are most frequently intestinal or pancreatobiliary adenocarcinomas but other subtypes, such as medullary, mucinous, or signet ring/poorly cohesive cell carcinoma, may be encountered. Ampullary cancer can also be subclassified based on immunohistochemical features, however these classification systems fail to show robust prognostic reliability. More recently, the molecular landscape of AC has been uncovered, and has been shown to have prognostic and predictive significance. In this article, the site-specific, histologic, and genetic characteristics of ampullary carcinoma and its precursor lesions are discussed.
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Affiliation(s)
- Yue Xue
- Department of Pathology and Laboratory Medicine, Northwestern University, 251 East Huron Street, Room 7332, Chicago, IL 60611, USA
| | - Michelle D Reid
- Department of Pathology and Laboratory Medicine, Emory University Hospital, 1364 Clifton Road Northeast, Room H 180A, Atlanta, GA 30322, USA.
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18
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Gericke M, Mende M, Schlichting U, Niedobitek G, Faiss S. Repeat full-thickness resection device use for recurrent duodenal adenoma: A case report. World J Gastrointest Endosc 2020; 12:193-197. [PMID: 32843929 PMCID: PMC7415228 DOI: 10.4253/wjge.v12.i6.193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/25/2020] [Accepted: 05/17/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic full-thickness resection of adenomas or subepithelial tumors is a novel and promising endoscopic technique. There have been several recent studies of full-thickness resection device (FTRD) use in the colon, but data regarding its use and efficacy in the duodenum are still limited.
CASE SUMMARY A 64-year-old female underwent resection of a recurrent adenoma of 7 mm in size in the duodenum after FTRD use for an adenoma eight months prior. The biopsies revealed a low-grade adenoma. The adenoma was removed using the gastroduodenal FTRD, and the pathology results revealed clear margins. Except for minor bleeding that was treated by argon plasma coagulation, no further complications occurred.
CONCLUSION Repeat use of the FTRD appears to be a safe and efficacious approach for the treatment of recurrent duodenal lesions. Further prospective studies are needed to investigate the long-term safety and utility of repeat FTRD use after Endoscopic full-thickness resection.
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Affiliation(s)
- Maximilian Gericke
- Department of Gastroenterology, Sana Klinikum Lichtenberg, Berlin 13065, Germany
| | - Matthias Mende
- Department of Gastroenterology, Sana Klinikum Lichtenberg, Berlin 13065, Germany
| | - Uwe Schlichting
- Department of Pathology, Sana Klinikum Lichtenberg, Berlin 13065, Germany
| | - Gerald Niedobitek
- Department of Pathology, Sana Klinikum Lichtenberg, Berlin 13065, Germany
| | - Siegbert Faiss
- Department of Gastroenterology, Sana Klinikum Lichtenberg, Berlin 13065, Germany
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Pavlovic-Markovic A, Dragasevic S, Krstic M, Stojkovic Lalosevic M, Milosavljevic T. Assessment of Duodenal Adenomas and Strategies for Curative Therapy. Dig Dis 2019; 37:374-380. [PMID: 30921797 DOI: 10.1159/000496697] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/08/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The increasing incidence of duodenal neoplasm has underlined different methods of resection depending on the clinical presentation, endoscopic features and histopathology. In this comprehensive review, we systematically describe the current knowledge concerning the diagnosis and management of duodenal adenomas (DAs) and discuss data considering all possible therapeutic approaches. SUMMARY Among a variety of duodenal lesions, including neuroendocrine tumors and gastrointestinal stromal tumors, DAs present precancerous lesions of the duodenal papilla or non-ampullary region necessitating removal. DAs can occur sporadically (SDA) as rare lesions or relatively common in polyposis syndromes. The endoscopic resections of DA are associated with an increased degree of complexity due to distinctive anatomical properties of the duodenal wall, luminal diameter and the presence of ampulla with pancreatic and biliary drainage. The endoscopic techniques including cold snare polypectomy (CSP), endoscopic mucosal resection (EMR), and argon plasma coagulation ablation are suggested to be less invasive than surgical treatment, associated with shorter hospital stay and lower cost. According to the current clinical practice, surgery has been accepted as standard therapeutic approach in familial adenomatous polyposis patients with severe polyposis or DA not amenable to endoscopic resection. Key Messages: The strategy for endoscopic resection of DAs depends on the lesion size, morphology, location, and histopathology findings. Small adenomas are most frequently diagnosed and removed by standard CSP techniques, while large laterally spreading lesions and ampullary adenoma are referred for EMR or endoscopic papillectomy respectively. Screening colonoscopy is indicated in patients with SDA. Additional studies for new endoscopic strategies and techniques for curative therapy of DAs are needed to refine future management decisions. Complete resection of DA is considered curative, but nevertheless, long-term endoscopic follow-up is still required to detect and treat any recurrent arising lesions.
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Affiliation(s)
- Aleksandra Pavlovic-Markovic
- Clinic for Gastroenterology and Hepatology, Clinical Center Serbia, Belgrade, Serbia, .,School of Medicine, University of Belgrade, Belgrade, Serbia,
| | - Sanja Dragasevic
- Clinic for Gastroenterology and Hepatology, Clinical Center Serbia, Belgrade, Serbia
| | - Miodrag Krstic
- Clinic for Gastroenterology and Hepatology, Clinical Center Serbia, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Tomica Milosavljevic
- Clinic for Gastroenterology and Hepatology, Clinical Center Serbia, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
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20
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Hara Y, Goda K, Dobashi A, Ohya TR, Kato M, Sumiyama K, Mitsuishi T, Hirooka S, Ikegami M, Tajiri H. Short- and long-term outcomes of endoscopically treated superficial non-ampullary duodenal epithelial tumors. World J Gastroenterol 2019; 25:707-718. [PMID: 30783374 PMCID: PMC6378536 DOI: 10.3748/wjg.v25.i6.707] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/31/2018] [Accepted: 01/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND It is widely recognized that endoscopic resection (ER) of superficial non-ampullary duodenal epithelial tumors (SNADETs) is technically challenging and may carry high risks of intraoperative and delayed bleeding and perforation. These adverse events could be more critical than those occurring in other levels of the gastrointestinal tract. Because of the low prevalence of the disease and the high risks of severe adverse events, the curability including short- and long-term outcomes have not been standardized yet.
AIM To investigate the curability including short- and long-term outcomes of ER for SNADETs in a large case series.
METHODS This retrospective study included cases that underwent ER for SNADETs at our university hospital between March 2004 and July 2017. Short-term outcomes of ER were measured based on en bloc and R0 resection rates as well as adverse events. Long-term outcomes included local recurrence detected on endoscopic surveillance and disease-specific mortality in patients followed up for ≥ 12 mo after ER.
RESULTS In the study, 131 patients with 147 SNADETs were analyzed. The 147 ERs consisted of 136 endoscopic mucosal resections (EMRs) (93%) and 11 endoscopic submucosal dissections (ESDs) (7%). The median tumor diameter was 10 mm. The pathology diagnosis was adenocarcinoma (56/147, 38%), high-grade intraepithelial neoplasia (44/147, 30%), or low-grade intraepithelial neoplasia (47/147, 32%). The R0 resection rate was 68% (93/136) in the EMR group and 73% (8/11) in the ESD group, respectively. Cap-assisted EMR (known as EMR-C) showed a higher rate of R0 resection compared to the conventional method of EMR using a snare (78% vs 62%, P = 0.06). No adverse event was observed in the EMR group, whereas delayed bleeding, intraoperative perforation, and delayed perforation in 3, 3, and 5 patients occurred in the ESD group, respectively. One patient with perforation required emergency surgery. In the 43 mo median follow-up period, local recurrence was found in four EMR cases and all cases were treated endoscopically. No patient died due to tumor recurrence.
CONCLUSION Our findings suggest that ER provides good long-term outcomes in the patients with SNADETs. EMR is likely to become the safe and reliable treatment for small SNADETs.
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Affiliation(s)
- Yuko Hara
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Kenichi Goda
- Department of Gastroenterology, Dokkyo Medical University, Tochigi 321-0293, Japan
| | - Akira Dobashi
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Tomohiko Richard Ohya
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Masayuki Kato
- Department of Endoscopy, The Jikei University Katsushika Medical Center, Tokyo 125-8506, Japan
| | - Kazuki Sumiyama
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Takehiro Mitsuishi
- Department of Pathology, The Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Shinichi Hirooka
- Department of Pathology, The Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Masahiro Ikegami
- Department of Pathology, The Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Hisao Tajiri
- Department of Innovative Interventional Endoscopy Research, The Jikei University School of Medicine, Tokyo 105-8461, Japan
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Sakaguchi Y, Yamamichi N, Tomida S, Takeuchi C, Kageyama-Yahara N, Takahashi Y, Shiogama K, Inada KI, Ichinose M, Fujishiro M, Koike K. Identification of marker genes and pathways specific to precancerous duodenal adenomas and early stage adenocarcinomas. J Gastroenterol 2019; 54:131-40. [PMID: 29951927 DOI: 10.1007/s00535-018-1489-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 06/22/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND The mechanism behind the pathogenesis and carcinogenesis of these neoplasms is not fully understood. The objective of this study was to identify genetic markers and pathways specific to precancerous duodenal adenomas and early stage adenocarcinomas through gene expression analysis. METHODS Gene expression profiling was performed in 4 pairs of duodenal adenoma/adenocarcinomas and corresponding matched normal tissue. Genes with consistent expression differences were identified and confirmed in 7 independent pairs. Gene set enrichment analysis (GSEA) was performed to characterize gene expression profiles of duodenal adenoma/adenocarcinomas, together with immunohistochemical staining of candidate oncogenic genes. RESULTS 626 probes consistently demonstrated over a twofold expression difference between tumor-normal pairs. Reverse transcriptase polymerase chain reaction of genes with the most prominent difference in expression between tumors and normal mucosa (KLK7, KLK6, CEMIP, MMP7, KRT17, LGR5, G6PC, S100G, APOA1) validated the results of gene expression analysis. GSEA demonstrated a strong association between duodenal adenoma/adenocarcinomas with colorectal adenomas (p < 10-5) and gene expression patterns seen after APC gene knockout (p < 10-5), suggesting that the Wnt/β-catenin pathway plays a crucial role in the carcinogenesis of these neoplasms. Immunohistochemical staining of an independent group of duodenal adenomas confirmed over-accumulation of β-catenin in 80.0% (16/20). CONCLUSIONS Precancerous duodenal adenomas and early stage adenocarcinomas demonstrate gene expression characteristics with a strong resemblance to colorectal adenomas. The results of this study strongly suggest that upregulation of the Wnt/β-catenin pathway is the major factor involved in the initial stages of the carcinogenesis of duodenal adenocarcinomas.
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Valli PV, Mertens JC, Sonnenberg A, Bauerfeind P. Nonampullary Duodenal Adenomas Rarely Recur after Complete Endoscopic Resection: A Swiss Experience Including a Literature Review. Digestion 2018; 96:149-157. [PMID: 28854423 DOI: 10.1159/000479625] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/17/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Duodenal polyps and especially duodenal adenomas are a rare and mostly coincidental finding in patients undergoing upper gastrointestinal endoscopy. Due to their malignant potential, duodenal adenomas should be removed upon diagnosis. So far, the limited available data on the performance of endoscopic polypectomy show conflicting results with regard to adverse events and the adenoma recurrence rate. PATIENTS AND METHODS After summarizing the currently available data, we retrospectively analyzed all patients undergoing endoscopic resection of nonampullary duodenal adenomas (NAD) at our institution between 2006 and 2016. RESULTS A total of 78 patients underwent endoscopic polypectomy for NAD adenoma. End-of-treatment success with complete resection requiring a mean of 1.2 interventions was achieved in 91% (n = 71). Procedural hemorrhage occurred in 12.8% (n = 10), whereas delayed bleeding was noted in 9% (n = 7). Duodenal perforation was registered and successfully treated in 2 cases (2.6%). No adenoma recurrence was noted following primary complete adenoma resection after a mean follow-up time of 33 months. Acute post-polypectomy bleeding was statistically significantly associated with large polyp size (p = 0.003) and lack of endoscopic prophylaxis (p = 0.0008). Delayed post-polypectomy bleeding showed a trend in the occurrence of large polyps (p = 0.064), and was statistically significantly associated with familial cancer syndrome (p = 0.019) and advanced histopathology (p = 0.013). CONCLUSION Our data suggest that endoscopic polypectomy of NAD is well feasible with high success rates. Procedural and delayed hemorrhage seems to be the primary issue rather than adenoma recurrence. We therefore advocate referral of patients with large NAD to experienced centers for endoscopic resection.
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Affiliation(s)
- Piero V Valli
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
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Kojima Y, Ohtsuka K, Ohnishi H, Abe N, Furuse J, Watanabe T, Sugiyama M. APC:T1556fs and STK11 mutations in duodenal adenomas and adenocarcinomas. Surg Today 2018; 48:765-72. [PMID: 29525853 DOI: 10.1007/s00595-018-1649-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Duodenal adenoma and adenocarcinoma (AC) are rare tumors, and few studies have examined their genetic features. We aimed to determine the key genetic changes in duodenal adenoma and AC, and to clarify the possible involvement of the adenoma-carcinoma sequence in duodenal tumor carcinogenesis. METHODS Nineteen duodenal tumors collected by endoscopic mucosal resection or surgical resection were classified as AC, adenoma with high-grade dysplasia (HGD), or adenoma with low-grade dysplasia (LGD) per the World Health Organization tumor classification. When a tumor contained two or more components with different dysplasia grades, the highest grade was assigned as the tumor grade. Representative areas of these components with different grades were microdissected and evaluated by a genomic analysis. Mutational hotspots involving 50 oncogenes and tumor suppressor genes were analyzed by next-generation sequencing, and their association with the dysplasia grade was investigated. RESULTS We analyzed 27 tumor components of AC or adenoma, with 11 normal mucosal samples obtained from 19 patients with duodenal tumors. The most prevalent abnormality among 50 genes tested was the KRAS mutation, which was detected in 12/19 (63.2%) patients, followed by APC and TP53 mutations (47.4 and 36.8%, respectively). According to the tumor dysplasia grading of each component, KRAS mutations were found in 5/8 (62.5%) tumors with AC components, 6/9 (66.7%) tumors with HGD components, and 3/10 (30.0%) tumors with LGD components. TP53 mutations were found in 4/8 (50.0%) tumors with AC components, 3/9 (33.3%) tumors with HGD components, and 1/10 (10.0%) tumors with LGD components. APC mutations were found in 2/8 (25.0%) tumors with AC components, 6/9 (66.7%) tumors with HGD components, and 5/10 (50.0%) tumors with LGD components. Notably, an APC:T1556fs mutation was detected in six cases (31.6%), five of which were adenoma cases. Furthermore, STK11 mutations were confirmed in 2/8 (25.0%) AC cases and in 1/11 (9.1%) adenoma cases. CONCLUSION APC:T1556fs and STK11 mutations found in duodenal adenomas/ACs highlight the importance of proteins encoded by these genes in tumor development. APC mutations were identified in duodenal adenomas more frequently than in duodenal ACs, which differed from the observations of typical adenoma-carcinoma sequences seen in colorectal cancer, suggesting the limited involvement of this mechanism in duodenal cancer development.
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Rajkomar K, Kweon M, Khan I, Frankish P, Rodgers M, Koea JB. Endoscopic assessment and management of sporadic duodenal adenomas: The results of single centre multidisciplinary management. World J Gastrointest Endosc 2017; 9:196-203. [PMID: 28465787 PMCID: PMC5394727 DOI: 10.4253/wjge.v9.i4.196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 01/22/2017] [Accepted: 03/02/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To review the role of multidisciplinary management in treating sporadic duodenal adenomas (SDA).
METHODS SDA managed at North Shore Hospital between 2009-2014 were entered into a prospective database. Pathology, endoscopic and surgical management as well as follow up were reviewed.
RESULTS Twenty-eight patients (14 male: Median age 68 years) presented with SDA [18 were classified as non ampullary location (NA), 10 as ampullary location (A)]. All SDA were diagnosed on upper gastrointestinal endoscopy and were imaged with a contrast enhanced CT scan of the chest, abdomen and pelvis. Of the NA adenomas 14 were located in the second part, 2 in the first part and 2 in the third part of the duodenum. Two patients declined treatment, 3 patients underwent surgical resection (2 transduodenal resections and 1 pancreaticoduodenectomy), and 23 patients were treated with endoscopic mucosal resection (EMR). The only complication with endoscopic resection was mild pancreatitis post procedure. Patients were followed with gastroduodenoscopy for a median of 22 mo (range: 2-69 mo). There were 8 recurrences treated with EMR with one patient proceeding to pancreaticodeuodenectomy because of high grade dysplasia in the resected specimen and 2 NA recurrences were managed with surgical resection (distal gastrectomy for a lesion in the first part of the duodenum and a transduodenal resection of a lesion in the third part of the duodenum).
CONCLUSION SDA can be treated endoscopically with minimal morbidity and piecemeal resection results in eradication in nearly three quarters of patients. Recurrent SDA can be treated with endoscopic reresection with surgical resection indicated when the lesions are large (> 4 cm in diameter) or demonstrate severe dysplasia or invasive cancer.
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Tomizawa M, Shinozaki F, Motoyoshi Y, Sugiyama T, Yamamoto S, Ishige N. Duodenal Adenocarcinoma Diagnosed from a Biopsy Specimen of a Depressed Lesion Obtained by Magnifying Endoscopy. Case Rep Gastroenterol 2016; 10:161-7. [PMID: 27403120 PMCID: PMC4929374 DOI: 10.1159/000444441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 02/02/2016] [Indexed: 12/13/2022] Open
Abstract
Biopsies are necessary for the management of duodenal tumors. However, the most suitable targets for biopsy are not known. An 82-year-old woman who regularly visited our hospital for rheumatoid arthritis underwent abdominal ultrasonography. This screening revealed a dilated pancreatic duct. Magnetic resonance cholangiopancreatography was performed, and dilatation of the pancreatic duct was confirmed. The patient underwent duodenoscopy to investigate the possibility of obstruction of the papilla of Vater. The examination revealed an elevated lesion around the papilla of Vater. Endoscopic ultrasonography and a 20-MHz mini-probe were used to investigate the depth of the invasion. The common bile and pancreatic ducts were intact. The mucosal and submucosal borders were indistinct; however, the border between the submucosa and muscularis propria was clear, suggesting that the muscularis propria was intact. Magnifying endoscopy was used to examine the surface of the elevated lesion, which revealed a depressed lesion. A biopsy specimen of the depressed lesion was taken, and the tumor was diagnosed as an adenocarcinoma. Another biopsy specimen from a non-depressed lesion was diagnosed as an adenoma. The patient was diagnosed with duodenal adenocarcinoma, and was recommended surgery. She declined surgery and was followed up for 34 months. Because it is possible for depressed lesions of duodenal tumors to be adenocarcinomas, biopsy specimens should be obtained from depressed lesions of duodenal tumors.
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Affiliation(s)
- Minoru Tomizawa
- Department of Gastroenterology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Japan
| | - Fuminobu Shinozaki
- Department of Radiology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Japan
| | - Yasufumi Motoyoshi
- Department of Neurology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Japan
| | - Takao Sugiyama
- Department of Rheumatology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Japan
| | - Shigenori Yamamoto
- Department of Pediatrics, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Japan
| | - Naoki Ishige
- Department of Neurosurgery, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Japan
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Abe N, Hashimoto Y, Kawaguchi S, Shimoyama H, Kojima Y, Yoshimoto E, Kondo E, Ohki A, Takeuchi H, Nagao G, Suzuki Y, Masaki T, Mori T, Sugiyama M. Successful treatment of large adenoma extending close to the papilla in the duodenum by laparoscopy-assisted pancreas-sparing duodenectomy. Asian J Endosc Surg 2016; 9:52-6. [PMID: 26781527 DOI: 10.1111/ases.12246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 08/20/2015] [Accepted: 09/03/2015] [Indexed: 12/16/2022]
Abstract
A 54-year-old man had a 65-mm infrapapillary, circular, and laterally spreading tubular adenoma in the distal second and proximal third parts of the duodenum. The papilla was 15 mm from the proximal margin of the tumor. Because the patient requested organ-preserving laparoscopic surgery, we conducted laparoscopy-assisted pancreas-sparing duodenectomy (LAPSD). LAPSD consists of five major procedures: (i) laparoscopic wide Kocher maneuver and transection of the proximal jejunum; (ii) laparoscopic separation of the duodenum from the pancreas; (iii) creation of a small upper median laparotomy; (iv) extracorporeal completion of the segmental duodenectomy; and (v) extracorporeal intestinal reconstruction. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. Histopathological examination revealed that the circumferential margin of the specimen was negative for tumor cells. LAPSD provided a clear margin without damaging the papilla and eliminated the possibility of peritoneal or port-site seeding of tumor cells because part of the procedure was performed extracorporeally. LAPSD is a useful alternative to pancreatoduodenectomy in patients with a large adenoma extending close to the papilla in the duodenum.
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Affiliation(s)
- Nobutsugu Abe
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | | | - Shouhei Kawaguchi
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Hayato Shimoyama
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Youhei Kojima
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Eri Yoshimoto
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Eri Kondo
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Atsuko Ohki
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Hirohisa Takeuchi
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Gen Nagao
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Yutaka Suzuki
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Tadahiko Masaki
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Toshiyuki Mori
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Masanori Sugiyama
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
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Lim CH, Cho YS. Nonampullary duodenal adenoma: Current understanding of its diagnosis, pathogenesis, and clinical management. World J Gastroenterol 2016; 22:853-861. [PMID: 26811631 PMCID: PMC4716083 DOI: 10.3748/wjg.v22.i2.853] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 08/10/2015] [Accepted: 10/26/2015] [Indexed: 02/06/2023] Open
Abstract
Nonampullary duodenal adenomas are relatively common in familial adenomatous polyposis (FAP), but nonampullary sporadic duodenal adenomas (SDAs) are rare. Emerging evidence shows that duodenal adenomas, regardless of their anatomic location and whether they are sporadic or FAP-related, share morphologic and molecular features with colorectal adenomas. The available data suggest that duodenal adenomas develop to duodenal adenocarcinomas via similar mechanisms. The optimal approach for management of duodenal adenomas remains to be determined. The techniques for endoscopic resection of duodenal adenoma include snare polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and argon plasma coagulation ablation. EMR may facilitate removal of large duodenal polyps. Although several studies have reported cases of successful ESD for duodenal adenomas, the procedure is technically difficult to perform safely because of the anatomical properties of the duodenum. Although current clinical practice recommends endoscopic resection of all large duodenal adenomas in patients with FAP, endoscopic treatment is usually insufficient to guarantee a polyp-free duodenum. Surgery is indicated for FAP patients with severe polyposis or nonampullary SDAs or FAP-related polyps not amenable to endoscopic resection. Further studies are needed to develop newer endoscopic techniques to guide diagnostic and therapeutic decisions for future management of nonampullary duodenal adenomas.
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Yang D, Reinhard MK, Wagh MS. Feasibility and safety of endoscopic cryoablation at the duodenal papilla: Porcine model. World J Gastrointest Endosc 2015; 7:728-735. [PMID: 26140100 PMCID: PMC4482832 DOI: 10.4253/wjge.v7.i7.728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 01/27/2015] [Accepted: 04/02/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To assess the feasibility and safety of liquid nitrogen spray cryoablation at the duodenal papilla in a porcine model.
METHODS: This prospective study protocol was approved by the University of Florida Institutional Animal Care and Use Committee. Six pigs underwent liquid nitrogen spray cryotherapy at the duodenal papilla. Freeze time of 20-s was applied per cycle (4 cycles/session). Survival animals (n = 4) were monitored for adverse events. Hemoglobin, white blood count, liver tests, and lipase were obtained at baseline and post-treatment. EGD was performed on day#7 to evaluate the papilla and for histology. All animals were euthanized and necropsy was performed at the end of the one-week survival period. Feasibility was defined as successful placement of the decompression tube in the duodenum, followed by delivery of spray cryotherapy to the duodenal papilla. Safety was determined by monitoring post-treatment blood tests and clinical course. Treatment effect was defined as endoscopic and histologic changes after cryotherapy. This was established by comparing endoscopic and histologic findings from mucosal biopsies prior to cryotherapy and on post-operative day (POD)#7. Full-thickness specimen was obtained post-mortem to assess depth of injury.
RESULTS: Spray cryotherapy was feasible and successfully performed in all 6/6 (100%) animals. Cryospray with liquid nitrogen (four 20-s freeze-thaw cycles) at the duodenal papilla resulted in white frost formation at and around the target region. The mean procedural time was 54.5 min (range 50-58 min). All six animals studied had stable blood pressure, heart rate, and pulse oximetry measurements during the procedure. There were no significant intra-procedural adverse events. There were no significant differences in hemoglobin, white cell count, liver tests or lipase from baseline to post-cryotherapy. Survival animals were monitored daily post-operatively without any clinical ill effects from the cryotherapy. There was no bleeding, infection, or perforation on necropsy. Endoscopic on POD#7 showed edema and ulceration at the duodenal papilla. On histology, there was loss of crypt architecture with moderate to severe necrosis and acute mixed inflammatory infiltration in each specimen following cryotherapy. The extent of cryogen-induced tissue necrosis (depth of injury) was limited to the mucosa on full-thickness specimen evaluation.
CONCLUSION: Endoscopic liquid nitrogen spray cryotherapy is feasible and safe for ablation at the duodenal papilla in a porcine model.
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Kakushima N, Kanemoto H, Sasaki K, Kawata N, Tanaka M, Takizawa K, Imai K, Hotta K, Matsubayashi H, Ono H. Endoscopic and biopsy diagnoses of superficial, nonampullary, duodenal adenocarcinomas. World J Gastroenterol 2015; 21:5560-5567. [PMID: 25987780 PMCID: PMC4427679 DOI: 10.3748/wjg.v21.i18.5560] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 12/10/2014] [Accepted: 01/08/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the accuracy of endoscopic or biopsy diagnoses of superficial nonampullary duodenal epithelial tumors (NADETs). METHODS Clinicopathological data were reviewed for 84 superficial NADETs from 74 patients who underwent surgery or endoscopic resection between September 2002 and August 2014 at a single prefectural cancer center. Superficial NADETs were defined as lesions confined to the mucosa or submucosa. Demographic and clinicopathological data were retrieved from charts, endoscopic and pathologic reports. Endoscopic reports included endoscopic diagnosis, location, gross type, diameter, color, and presence or absence of biopsy. Endoscopic diagnoses were made by an endoscopist in charge of the examination before biopsy specimens were obtained. Endoscopic images were obtained using routine, front-view, high-resolution video endoscopy, and chromoendoscopy with indigocarmine was performed for all lesions. Endoscopic images were reviewed by at least two endoscopists to assess endoscopic findings indicative of carcinoma. Preoperative diagnoses based on endoscopy and biopsy findings were compared with histological diagnoses of resected specimens. Sensitivity, specificity, and accuracy were assessed for endoscopic diagnosis and biopsy diagnosis. RESULTS The majority (81%) of the lesions were located in the second portion of the duodenum. The median lesion diameter was 14.5 mm according to final histology. Surgery was performed for 49 lesions from 39 patients, and 35 lesions from 35 patients were endoscopically resected. Final histology confirmed 65 carcinomas, 15 adenomas, and 3 hyperplasias. A final diagnosis of duodenal carcinoma was made for 91% (52/57) of the lesions diagnosed as carcinoma by endoscopy and 93% (42/45) of the lesions diagnosed as carcinoma by biopsy. The sensitivity, specificity, and accuracy of endoscopic diagnoses were 80%, 72%, and 78%, respectively, whereas those of biopsy diagnoses were 72%, 80%, and 74%, respectively. Preoperative diagnoses of carcinomas were made in 88% (57/65) of the carcinoma lesions via endoscopy or biopsy. Endoscopic findings associated with carcinoma were red color, depression, and mixed-type morphology. CONCLUSION Preoperative endoscopy and biopsy showed similar accuracies in the diagnosis of carcinoma in patients with superficial NADETs.
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Abstract
Duodenal endoscopic submucosal dissection (ESD) is technically difficult due to the unique anatomic features. The risks include intraprocedural complications, delayed bleeding, and perforation. A small-caliber-tip transparent hood is useful. Mechanical stretching of the submucosal tissue allows safe dissection and effective prevention of bleeding with minimum muscle injury under direct visualization of the submucosal tissue and blood vessels. A short double-balloon endoscope is useful to stabilize control of the endoscope tip in distal duodenal ESD. Selection of ESD in the duodenum should be made cautiously considering both benefits and risks of the procedure.
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Affiliation(s)
- Hironori Yamamoto
- Gastroenterology Center, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan.
| | - Yoshimasa Miura
- Gastroenterology Center, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
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Sakamoto H, Mutoh H, Miura Y, Sashikawa M, Yamamoto H, Sugano K. SOX9 Is Highly Expressed in Nonampullary Duodenal Adenoma and Adenocarcinoma in Humans. Gut Liver 2013; 7:513-8. [PMID: 24073307 PMCID: PMC3782664 DOI: 10.5009/gnl.2013.7.5.513] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 11/19/2012] [Accepted: 11/22/2012] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND/AIMS SOX9 is a marker for stem cells in the intestine, and overexpression of SOX9 is found in gastric and colon cancer; however, the expression of SOX9 in nonampullary duodenal adenoma and adenocarcinoma has not yet been evaluated. This study aimed to investigate SOX9 expression in nonampullary duodenal adenoma and adenocarcinoma by immunohistochemistry. METHODS We evaluated SOX9 expression in 43 clinical samples (nonampullary duodenal adenoma in 22 lesions and nonampullary duodenal adenocarcinoma in 21 lesions) resected under endoscopic mucosal resection or endoscopic submucosal dissection. RESULTS SOX9 was expressed in part of the base of the normal duodenal mucosa surrounding adenomas and adenocarcinomas. In contrast, SOX9-positive cells were found in more than half of the crypts from the bottom part of the crypt in all of the 43 samples. Moreover, in 15 adenoma samples (68.2%) and 19 carcinoma samples (90.5%), SOX9 was expressed in more than three-quarters of the crypts from the bottom part of the crypt. CONCLUSIONS SOX9 is overexpressed in nonampullary duodenal adenoma and adenocarcinoma in humans.
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Affiliation(s)
- Hirotsugu Sakamoto
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
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Freeman HJ. Appearance of attenuated intestinal polyposis during chronic non-steroidal anti-inflammatory drugs use. World J Gastrointest Pharmacol Ther 2012; 3:100-2. [PMID: 23494537 PMCID: PMC3596514 DOI: 10.4292/wjgpt.v3.i6.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 11/09/2012] [Accepted: 11/20/2012] [Indexed: 02/06/2023] Open
Abstract
Aspirin and non-steroidal anti-inflammatory drugs (NSAIDS) may prevent sporadic colonic neoplasia and reduce the polyp burden in familial adenomatous polyposis. A 41-year-old pharmacologist with no family history of intestinal polyps or cancer chronically consumed daily aspirin and other non-steroidal anti-inflammatory drugs for decades despite recurrent and multiple gastric ulcers. A cancerous polyp in the colon was endoscopically resected. Over the next 2 decades, almost 50 adenomatous polyps were removed from the rest of his colon and duodenum, typical of an attenuated form of adenomatous polyposis. Chronic and habitual use of aspirin or NSAIDS may have important significance in delaying the appearance of adenomas. The observations here emphasize the important implications for clinical risk assessment in screening programs designed to detect or prevent colon cancer.
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Affiliation(s)
- Hugh James Freeman
- Hugh James Freeman, Department of Medicine, University of British Columbia, Vancouver, BC V6T 1W5, Canada
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