Efficacy of partial injection underwater endoscopic mucosal resection for superficial duodenal epithelial tumor: Propensity score-matched study (with video)

BACKGROUND AND AIM

Underwater endoscopic mucosal resection (UEMR) has been reported as effective endoscopic treatment for superficial duodenal epithelial tumors (SDETs). However, it has been reported that a notable problem of UEMR for SDETs is that en bloc resection rate is relatively low. Therefore, we proposed a novel technique to improve en bloc resection rate: UEMR combining partial submucosal injection (PI-UEMR). The aim of this study is to evaluate efficacy and safety of PI-UEMR for SDETs by comparing to UEMR.

METHODS

This is a retrospective observational study in a single center. The patients who underwent UEMR or PI-UEMR from June 2010 to August 2020 were included in this study. Eligible patients were selected from included patients in a 1:1 ratio using propensity score matching. The clinical outcomes of endoscopic resection (procedure time, en bloc resection rate, complication rate [immediate perforation, delayed bleeding, delayed perforation]), and histopathological diagnosis (adenoma/cancer) were compared between each group.

RESULTS

Two hundred and twenty-eight patients were included in this study. Of included patients, 47 patients were selected in each group by propensity score matching. There were no statistical differences in procedure time (11 ± 1.2 min vs. 9 ± 1.2 min, P = 0.30), complication rate (immediate perforation [0% vs. 2%, P = 0.12], delayed bleeding [0% vs. 2%, P = 0.12], and no delayed perforation) and histopathological diagnosis (adenoma; 100% vs. 96%, P = 0.14) in each group. However, en bloc resection rate of PI-UEMR was significantly higher than UEMR (96% vs. 83%, P < 0.05).

CONCLUSION

Partial submucosal injection UEMR might be superior procedure for en bloc resection in SDETs compare to UEMR.

Future of Endoscopy: Brief review of current and future endoscopic resection techniques for colorectal lesions

Endoscopic treatment of colorectal lesions has seen major developments in the last decade. It is now considered curative for intramucosal and superficial submucosal cancers. Endoscopic Mucosal Resection in expert hands has very good outcomes with low complication rates but recurrence and inadequate treatment of early cancers remain an issue. This has led to a technical evolution that can lead to one piece resection of neoplasia. This includes a range of techniques from knife assisted snare resection (KAR), endoscopic submucosal dissection (ESD) to full thickness resections. This article reviews all the resection techniques and the evidence base behind them.

"Underwater" EMR of sporadic laterally spreading nonampullary duodenal adenomas (with video)

BACKGROUND

EMR for the treatment of duodenal adenomas is challenging due to a thin wall and rich vascularity.

OBJECTIVE

To evaluate a novel technique of "underwater" EMR without prior submucosal injection for the removal of large (≥2 cm) laterally spreading nonampullary duodenal adenomas.

DESIGN

Prospective, observational study.

SETTING

Tertiary academic referral center.

PATIENTS

Twelve patients (median age, 60 years) meeting the inclusion criteria.

INTERVENTIONS

Piecemeal EMR technique after sterile water submersion when using a double-channel endoscope.

MAIN OUTCOME MEASUREMENTS

Technical success, adverse events, completeness of resection on follow-up endoscopy.

RESULTS

Median adenoma size was 35 mm (25% greater than one-half circumference, 50% equal to one-third to one-half circumference, and 25% less than one-third circumference). Median procedure time was 65 minutes (range, 32-151). Final histology was tubular adenoma (7), tubulovillous adenoma (1), villous adenoma (3), and high-grade dysplasia (1). Eleven patients (92%) met the primary endpoint (technical success) and all patients met the secondary endpoint (completeness of resection). Median interval until follow-up endoscopy was 16 weeks (range, 11-56). Adverse events were as follows: delayed bleeding (3 patients, of whom 2 required transfusions), water intoxication syndrome manifested by altered mental status and hyponatremia (1), and stricture formation (1) that responded to balloon dilation. No perforation or postresection abdominal pain was found.

LIMITATIONS

Single operator, single center, small sample size, limited follow-up.

CONCLUSION

Underwater EMR for large sessile duodenal adenomas has high success rates for complete removal. The risk of delayed bleeding is significant, and precautions are needed when infusing a large volume of fluid into the GI tract.