1192 The Safety, Efficacy, and Outcomes for the Endoscopic Resection of Large Non-Ampullary Duodenal Polyps in Familial Adenomatous Polyposis (FAP)

Abstract

INTRODUCTION: Nearly all patients with FAP will develop duodenal adenomas. Duodenal cancer is the leading cause of death in patients with FAP after colectomy. Risk of duodenal cancer can be predicted by the Spigelman staging (SS) system. Endoscopic resection (ER) of larger duodenal polyps is technically challenging because of the duodenum’s thin wall, narrow lumen, multiple folds, and increased vascularity. However, successful removal of these large duodenal lesions can potentially avoid foregut surgery by downstaging the SS. We evaluated the safety, feasibility, and outcomes, including the effect on SS, for the ER of large duodenal polyps in FAP. METHODS: This is a single-center retrospective cohort study including consecutive FAP patients who underwent ER of large (defined as >1.5 cm) duodenal polyps between 4/2016-2/2019. Resection techniques used included injection-assisted endoscopic mucosal resection (EMR) and hybrid EMR-Endoscopic submucosal dissection (ESD) by an advanced endoscopist specialized in endoscopic resection. Primary aim was to determine safety of the technique, particularly perforation, immediate (>2-gram hemoglobin drop < 48 hrs after procedure) and delayed (active bleeding from a post-resection ulcer diagnosed by emergency or planned follow-up endoscopy) bleeding. SS before and after resection was calculated. RESULTS: 35 unique FAP patients (48.6% male; age 47.7 years) with 55 large duodenal polyps were identified. All 35 underwent endoscopic resection (54 EMR, 1 ESD/EMR hybrid) of at least one large duodenal polyp [Table 1]. 7 polyps were resected from the duodenal bulb, 33 in D2, 10 in D3/D4, and 2 in the neoduodenum. Median lesion size is 2.4 cm [25-75 IQR:1.65-3], median procedure time 49 min[30-60], and median resection speed 0.16 cm2/min [0.073-0.208]. No duodenal perforations or delayed bleeding occurred. 1 case of immediate bleeding was managed endoscopically. 53/55 polyps were completely resected endoscopically. The 2 incomplete resections were poorly-lifting lesions, preventing safe resection. Of the 35 patients included, 25 had adequate endoscopic surveillance over the study period. 11/25 started at SS IV and 8 were downstaged to SS III (73%) with endoscopic resection, avoiding surgery (Figures 1 and 2). CONCLUSION: Endoscopic resection of large duodenal polyps in FAP is safe when performed with adequate expertise. Endoscopic resection of large polyps allows downstaging of advanced SS in many of these patients. Long-term benefit of downstaging needs to be further evaluated.