Endoscopic submucosal dissection for duodenal tumors: a single-center experience

• Introduction
• Case report
• Discussion
• References

The indications for endoscopic submucosal dissection (ESD) for duodenal tumors have not yet been established. We reviewed our experience of ESD performed for duodenal tumors. We analyzed the data of a total of 13 patients with 14 duodenal lesions (excluding papillary lesions) comprising 2 early cancers, 5 adenomas, and 7 neuroendocrine tumors, who were treated by ESD between 2005 and 2011. The mean tumor diameter was 12.7 ± 14.8 mm. En bloc resection was achieved in 85.7 % of the cases. The procedure time was 89.1 ± 64.6 minutes. Intraoperative perforation occurred in three cases. The mean length of postoperative hospitalization was 8.4 ± 2.4 days. Because ESD for duodenal lesions was associated with a higher incidence of perforation than ESD for lesions in other locations (stomach, esophagus, and colon) reported previously, its use for duodenal lesions should be considered with caution.

Introduction

Although endoscopic submucosal dissection (ESD) has been widely accepted as a therapeutic procedure, the use of this technique for duodenal lesions remains controversial because of the technical difficulties and the high frequency of procedural complications [1]; nonetheless, there have been some reports of clinical experience of its use [2] [3] [4]. However, there have been no reports discussing the appropriate indications for ESD for duodenal tumors. Therefore, in this study we reviewed our experience of ESD performed for duodenal lesions (excluding papillary lesions), with the aim of helping to establish the indications for using ESD to treat duodenal lesions in the future.

Case report

The subjects of the study were 13 patients with 14 duodenal lesions (excluding papillary lesions) treated by ESD at the Saitama Medical Center between 2005 and 2011. The demographic characteristics of the patients, together with details of the procedures, are presented in [Table 1]. The 14 lesions included in this study were 2 early cancers, 5 adenomas, and 7 neuroendocrine tumors (NETs). The average age of the patients was 68 ± 5 years (range, 57 – 79 years), with a male:female ratio of 5:8. Of the 14 lesions, 8 were located in the duodenal bulb and the remaining 6 in the descending part of the duodenum. The mean tumor diameter was 12.7 ± 14.8 mm (range, 3 – 60 mm). The en bloc resection rate was 85.7 % (12 /14 cases). Piecemeal resection was performed in one case of a large elevated-type adenoma (no. 6), while in one case of a NET invading the deep layer of the submucosa (no. 12), ESD was discontinued and local excision was performed. The resection time was 89.1 ± 64.6 minutes. Perforation occurred in three cases. Emergency surgery was necessitated in two cases. Postprocedural bleeding occurred in one case. The mean length of postoperative hospitalization was 8.4 ± 2.4 days. No case of recurrence has been seen to date.

Discussion

Endoscopic treatment of duodenal lesions is associated with a high incidence of complications, such as bleeding and perforation, because of the poor operability of lesions in this region using a scope, and because of the thinness of the duodenal wall. In particular, duodenal ESD is technically difficult, requires a longer procedure time, and is associated with a high risk of perforation [2] [3]. It is therefore important that the operator should be sufficiently skilled, with experience of having performed ESD safely and steadily at least for lesions in the stomach, esophagus, and large bowel.

When making the choice between endoscopic mucosal resection (EMR) and ESD in patients with duodenal tumors, the histopathology, macroscopic morphology, and size of the lesions should all be taken into account. EMR has been reported not only to be safe and useful for the treatment of duodenal adenomas, but also to yield a favorable long-term prognosis [5] [6]. Benign tumors such as hyperplastic polyps and adenomas can be safely resected piecemeal, and therefore EMR may be employed for such lesions. In comparison with en bloc resection, however, piecemeal resection is associated with a higher incidence of residual lesions and/or recurrence [6]. In addition, en bloc resection enables accurate pathological assessment of the deep and lateral margins of the resected lesions [7]. For this reason, en bloc resection is recommended for carcinomas and NETs; lesions amenable to en bloc resection by EMR may be resected by EMR, while those that are unlikely to be amenable to en bloc resection by EMR may be resected by ESD.

Among the complications associated with endoscopic treatment of duodenal lesions, bleeding is the most frequent and usually occurs within 24 hours after the procedure [5] [6] [8] [9]. Regarding perforation, caution is required to guard not only against intraprocedural perforation, but also against delayed perforation due to exposure to bile and pancreatic juice [2].

In conclusion, this study showed that ESD may be useful for some duodenal tumors. However, because duodenal ESD is associated with a relatively high incidence of complications, its use should be considered with caution. More clinical data need to be collected for clearer elucidation of the short-term and long-term outcomes of ESD for duodenal lesions.

Competing interests: None

• References

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Corresponding author

• References

• 1 Kim KO, Kim SJ, Kim TH et al. Do you have what it takes for challenging endoscopic submucosal dissection cases?. World J Gastroenterol 2011; 17: 3580-3584
  CrossrefPubMedSearch in Google Scholar
• 2 Honda T, Yamamoto H, Osawa H et al. Endoscopic submucosal dissection for superficial duodenal neoplasms. Dig Endosc 2009; 21: 270-274
  CrossrefPubMedSearch in Google Scholar
• 3 Matsumoto S, Miyatani H, Yoshida Y et al. Duodenal carcinoid tumors: 5 cases treated by endoscopic submucosal dissection. Gastrointest Endosc 2011; 74: 1152-1156
  CrossrefPubMedSearch in Google Scholar
• 4 Suzuki S, Ishii N, Uemura M et al. Endoscopic submucosal dissection (ESD) for gastrointestinal carcinoid tumors. Surg Endosc 2012; 26: 759-763
  CrossrefPubMedSearch in Google Scholar
• 5 Kim HK, Chung WC, Lee BI et al. Efficacy and long-term outcome of endoscopic treatment of sporadic nonampullary duodenal adenoma. Gut Liver 2010; 4: 373-377
  CrossrefPubMedSearch in Google Scholar
• 6 Alexander S, Bourke MJ, Williams SJ et al. EMR of large, sessile, sporadic nonampullary duodenal adenomas: technical aspects and long-term outcome (with videos). Gastrointest Endosc 2009; 69: 66-73
  CrossrefPubMedSearch in Google Scholar
• 7 Lépilliez V, Chemaly M, Ponchon T et al. Endoscopic resection of sporadic duodenal adenomas: an efficient technique with a substantial risk of delayed bleeding. Endoscopy 2008; 40: 806-810
  Thieme ConnectPubMedSearch in Google Scholar
• 8 Apel D, Jakobs R, Spiethoff A et al. Follow-up after endoscopic snare resection of duodenal adenomas. Endoscopy 2005; 37: 444-448
  Thieme ConnectPubMedSearch in Google Scholar
• 9 Sohn JW, Jeon SW, Cho CM et al. Endoscopic resection of duodenal neoplasms: a single-center study. Surg Endosc 2010; 24: 3195-3200
  CrossrefPubMedSearch in Google Scholar