Endoscopic submucosal dissection for sessile, nonampullary duodenal adenomas

• Introduction
• Patients and methods
• Study patients
• Endoscopic resection procedures
• Results
• Discussion
• References

Although endoscopic submucosal dissection (ESD) is increasingly utilized to treat early neoplasms of the gastrointestinal tract, its use for duodenal neoplasms is limited by the thin wall and narrow lumen of the duodenum. We have reviewed cases where ESD was used to treat sessile, nonampullary duodenal neoplasms. To do this, we retrospectively reviewed the medical records of patients treated with ESD for adenomas of the duodenum from January 2001 to December 2010, assessing the curative outcomes and complication rates. A total of 14 cases were reviewed. Mean patient age was 56.4 years. The mean size of tumors and mean size of the specimens were 17.1 mm and 26.4 mm, respectively. The en bloc resection rate with ESD was 78.6 %, and the complete (R₀) resection rate was 85.7 %. No patient in the study experienced major bleeding. However, second-look endoscopy revealed minor bleeding requiring endoscopic homeostasis in one case (7.1 %). Perforations were observed in five cases (35.7 %). Two of the five patients with perforation underwent surgery. The ESD methods yielded acceptable curative resection rates for duodenal adenomas, although ESD was associated with a higher rate of perforation. Therefore, duodenal ESD should be performed with care and only in selected patients to avoid serious complications.

Introduction

Primary duodenal neoplasms are very rare, although their incidence has increased with the larger number of people now undergoing screening endoscopy. Endoscopic mucosal resection (EMR) is widely used to treat neoplasms of the gastrointestinal tract, including adenomas, adenocarcinomas, and carcinoid tumors. More recently, the use of endoscopic submucosal dissection (ESD) to treat relatively large lesions in the stomach, large intestine, and esophagus has increased [1]. ESD, however, is rarely used to treat duodenal lesions due to the anatomical features of the duodenum, such as its thin walls and narrow lumen [2].

Although several recent case series have described outcomes in patients who underwent ESD for duodenal neoplasms, each of these series consisted of a small number of patients with a short follow-up [2] [3] [4] [5]. In the present study we reviewed the efficacy and safety of ESD in the treatment of patients with duodenal adenomas.

Patients and methods

Study patients

We retrospectively analyzed patients who underwent ESD for the treatment of an adenoma of the duodenum between January 2001 and December 2010 in the Department of Gastroenterology at the Asan Medical Center, Seoul, Korea. All patients included were followed up for at least 6 months. Patients with polyposis syndrome, pedunculated polyps, and ampullary lesions, patients treated with the EMR method (for any lesion), and those not followed up for at least 6 months were excluded. All patients gave their informed consent for all procedures carried out.

Endoscopic resection procedures

Endoscopic resection procedures were performed by five experienced gastrointestinal endoscopists (H. Y. J., J. H. L., H. J. S. K. D. C., and D. H. K.), each of whom had performed more than 300 ESD and more than 300 EMR procedures in the upper gastrointestinal tract prior to performing duodenal ESD.

Patients were sedated with intravenous midazolam (0.05 mg/kg) and pethidine (50 mg). Cardiorespiratory function was continually monitored throughout the procedure. We used a single-channel endoscope (GIF-Q260 J or GIF-H260; Olympus Optical Co., Ltd., Tokyo, Japan) and VIO 300 D (Erbe Elektromedizin GmbH, Tübingen, Germany) for the electrosurgical unit.

The ESD sequence consisted of marking, submucosal injection, precutting, and mucosal resection with a snare. Small dots were placed circumferentially outside the tumor using an argon plasma coagulation probe (Erbe). Saline solution containing epinephrine (0.01 mg/mL) and 0.8 % indigo carmine was injected into the submucosal layer using a 21-gauge needle (Olympus). A circumferential incision was made in the mucosa using a needle-knife (MTW Endoskopie Co., Ltd., Wesel, Germany), a hook-knife (KD-620LR; Olympus), or insulated-tip knives (KD-611L; Olympus or MTW). After precutting, insulated-tip knives were used to dissect the submucosal layer. Endoscopic hemostasis was performed with either the knife or hemostatic forceps (FD-410LR; Olympus) whenever bleeding occurred or a vessel was exposed. Perforations during the procedure were treated by immediate mucosal closure with hemoclips, followed by insertion of a nasogastric tube and natural drainage. Patients with resection site bleeding were reassessed by second-look endoscopy on the second day after the procedure.

Results

A total of 14 patients were included. The baseline characteristics of these patients are shown in [Table 1].

We compared the efficacy and safety of the two methods on the basis of treatment outcome ([Table 1]). The mean size of tumors and mean size of the specimens were 17.1 mm and 26.4 mm, respectively. The en bloc resection rate of ESD was 78.6 %, and its complete (R₀) resection rate was 84.2 %. The total procedure time and resection time were 32.0 minutes and 21.6 minutes, respectively.

No patient in the study group experienced major bleeding. However, second-look endoscopy revealed minor bleeding requiring endoscopic homeostasis in one case (7.1 %).

Perforations were observed in five cases (35.7 %). Of these, two were detected during submucosal dissection, one was detected just after submucosal dissection, and two were delayed.

Discussion

In the present study, ESD used to treat duodenal adenoma showed acceptable rates of en bloc resection (78.6 %) and complete resection (85.7 %). However, when we assessed complications, we found that the perforation rates were very high (35.7 %). ESD-related perforation rates are much lower when ESD is used to treat lesions in the stomach. For example, perforation rates associated with gastric ESD have been reported at between 1.2 % and 8.7 % [1] [6] [7] [8]. The endoscopists who performed the procedures in the present study previously reported a perforation rate of 2.1 % for gastric ESD used to treat early gastric cancer [9]. The difference between perforation rates in these two organs may be due to the thicker walls and wider lumen of the stomach compared to the duodenum, making the handling of endoscopic equipment easier in the stomach. Another possible reason is the presence of dense Brunner’s glands in duodenal submucosa. The dense duodenal submucosal glands may reduce the effects of the submucosal injections, which have an important role in preventing perforation through lifting of the submucosal layer. In comparison, perforation rates after colorectal ESD has been reported to be 1.4 % – 10.4 % [10] [11].

Duodenal perforation related to ESD is not uncommon. For example, an earlier study of 16 patients with duodenal adenomas, 11 treated by EMR and 5 by ESD, found that the only patient with a duodenal perforation was in the ESD group [5]. Another study of four patients with duodenal adenoma and adenocarcinoma who underwent ESD found duodenal perforations in two of these patients [4]. In another report, of nine patients with duodenal adenoma and adenocarcinoma treated with ESD, two suffered a duodenal perforation [3]. The perforation rate we observed after duodenal ESD (35.7 %) is thus consistent with the rates reported previously (20 % – 50 %).

In our present study, of the five patients with perforations after ESD, two required surgical conversion. Surgical conversion rates for perforation after gastric ESD have been reported to range from 0 % to 3.3 % [6] [7] [9]. However, it has also been reported that 0 % – 6.7 % of perforations after ESD in the large intestine require surgical treatment [10] [11]. The thick wall of the stomach and the antibacterial effects of gastric acid may suppress the progression of peritonitis [8]. For the duodenum, appropriate endoscopic clipping after perforation is difficult since its lumen is narrow and winding.

The rates of delayed perforation reported after gastric and colorectal ESD are 0.45 % and 0.3 % – 0.7 %, respectively [7] [8] [10]. In comparison, we observed delayed perforation rates after duodenal ESD of 14.3 % (2 /14). The higher frequency of delayed perforation after duodenal ESD may be due to the thinness of the duodenal walls, coupled with proteinolysis or chemical irritation by pancreatic enzymes and bile juice. Moreover, electrocauterization, a well-known risk factor for delayed perforation after endoscopic treatment, is more frequently required during ESD than during EMR [7].

Due to the small number of enrolled patients and perforation cases in our study, it is not clear whether ESD itself or a larger size of tumor is closely associated with the perforation. However, in the case of the large intestine, ESD has been shown to be associated with a higher perforation rate than EMR for the same tumor size [12]. For this reason, we predict that ESD itself is risk factor for perforation in the treatment of duodenal neoplasms. Several previous studies have suggested that single-session or multi-session piecemeal EMR is safe and efficient for treating superficial premalignant neoplasms of the duodenum. Although further studies are needed to directly compare ESD and multi-session piecemeal EMR, we speculate that single-session or multi-session piecemeal EMR might be an alternative treatment for premalignant duodenal lesions [13].

In conclusion, ESD for duodenal adenoma is efficient but is associated with a high perforation rate. In order to avoid serious complications, therefore, this procedure should be performed with care and only in selected patients.

Competing interests: None

• References

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• 12 Kobayashi N, Yoshitake N, Hirahara Y et al. A matched case-control study comparing endoscopic submucosal dissection and endoscopic mucosal resection for colorectal tumors. J Gastroenterol Hepatol 2012; 27: 728-733
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Corresponding author

• References

• 1 Oka S, Tanaka S, Kaneko I et al. Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer. Gastrointest Endosc 2006; 64: 877-883
  CrossrefPubMedSearch in Google Scholar
• 2 Shinoda M, Makino A, Wada M et al. Successful endoscopic submucosal dissection for mucosal cancer of the duodenum. Dig Endosc 2010; 22: 49-52
  CrossrefPubMedSearch in Google Scholar
• 3 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
• 4 Takahashi T, Ando T, Kabeshima Y et al. Borderline cases between benignancy and malignancy of the duodenum diagnosed successfully by endoscopic submucosal dissection. Scand J Gastroenterol 2009; 44: 1377-1383
  CrossrefPubMedSearch in Google Scholar
• 5 Endo M, Abiko Y, Oana S et al. Usefulness of endoscopic treatment for duodenal adenoma. Dig Endosc 2010; 22: 360-365
  CrossrefPubMedSearch in Google Scholar
• 6 Akasaka T, Nishida T, Tsutsui S et al. Short-term outcomes of endoscopic submucosal dissection (ESD) for early gastric neoplasm: multicenter survey by Osaka University ESD study group. Dig Endosc 2011; 23: 73-77
  CrossrefPubMedSearch in Google Scholar
• 7 Hanaoka N, Uedo N, Ishihara R et al. Clinical features and outcomes of delayed perforation after endoscopic submucosal dissection for early gastric cancer. Endoscopy 2010; 42: 1112-1115
  Thieme ConnectPubMedSearch in Google Scholar
• 8 Abe Y, Inamori M, Iida H et al. Clinical characteristics of patients with gastric perforation following endoscopic submucosal resection for gastric cancer. Hepatogastroenterology 2009; 56: 921-924
  PubMedSearch in Google Scholar
• 9 Ahn JY, Choi KD, Choi JY et al. Procedure time of endoscopic submucosal dissection according to the size and location of early gastric cancers: analysis of 916 dissections performed by 4 experts. Gastrointest Endosc 2011; 73: 911-916
  CrossrefPubMedSearch in Google Scholar
• 10 Saito Y, Fukuzawa M, Matsuda T et al. Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection. Surg Endosc 2010; 24: 343-352
  CrossrefPubMedSearch in Google Scholar
• 11 Kim ES, Cho KB, Park KS et al. Factors predictive of perforation during endoscopic submucosal dissection for the treatment of colorectal tumors. Endoscopy 2011; 43: 573-578
  Thieme ConnectPubMedSearch in Google Scholar
• 12 Kobayashi N, Yoshitake N, Hirahara Y et al. A matched case-control study comparing endoscopic submucosal dissection and endoscopic mucosal resection for colorectal tumors. J Gastroenterol Hepatol 2012; 27: 728-733
  CrossrefPubMedSearch in Google Scholar
• 13 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