1696 Is It Technically Feasible to Use Duodenoscopy in Endoscopic Submucosal Dissection for the Recurrent Laterally Spreading Ampullary Adenomas?

Abstract

INTRODUCTION: The management strategies of recurrent ampullary adenomas after endoscopic papillectomy is still a controversial issue regarding the best modality for treatment. The aim of the study is to assess the feasibility, efficacy and safety of duodenoscopic submucosal dissection (DESD) for the recurrent laterally spreading ampullary duodenal lesion. CASE DESCRIPTION/METHODS: We prospectively enrolled two patients with recurrent laterally spreading ampullary duodenal adenomas after successful papillectomy. Following marking the resection borders of the lesion using a Dual knife, a submucosal cushion is created by injecting a mixture of saline solution, methylene blue and adrenaline. A circumferential incision followed by submucosal dissection was performed using Dual knife and IT knife, then the lesion was resected using an electric snare. Hemostasis was applied using coagulation grasper during the procedure. Following dissection ERCP with biliary and pancreatic stenting was performed. Finally closure of the resection site was achieved using Endo-clipping in order to prevent complications such as secondary hemorrhage and delayed perforation. DESD followed by biliary and pancreatic stenting was performed successfully for two patients with recurrent laterally spreading ampullary duodenal adenomas. Table 1 shows the procedure details for the initial papillectomy which showed En-bloc resection of both lesions. Table 2 shows detailed current characteristics and procedure details for the recurrent lesions. Figures 1 and 2 Show endoscopic procedures. The average total procedure time was 95.5 mins, and the procedure time of DESD and ERCP was 38.5 mins and 15.5 mins respectively with no serious intra-or post procedure complication. The histopathological examinations revealed tubulovillous adenoma with negative resection margins in case 1. Unfortunately specimen of case 2 was not retrieved successfully. Follow up at the third, sixth and twelfth month showed no residual or recurrent lesions in ampullary areas, biopsy of resection site showed inflammation with absence of adenomatous tissues in both cases. DISCUSSION: In conclusion, DESD is technically challenging, potentially effective and curative for laterally spreading duodenal ampullary adenomas within 2 cm in diameter. It should be performed cautiously in selected patients by experts with abundant experience in performing not only ESD but also ERCP. Watch the video: http://bit.ly/2Y4dE77.