Characteristics of Duodenal Neoplasms That Impact the Decision of Endoscopic Or Surgical Management: Experience At a Large, Tertiary Referral Center

Abstract

Introduction: Duodenal neoplasms are being encountered more frequently. With advances in endoscopic tools and techniques, these lesions are increasingly being managed by interventional endoscopists over surgery. The aim of this study was to delineate the characteristics of duodenal neoplasms and determine if location, size, or histology impacts the therapeutic management undertaken. Methods: A retrospective review was performed on all patients with a biopsy-proven duodenal neoplasm evaluated at a multidisciplinary, large volume, tertiary referral center, between the years 2000 and 2005. Results: A total of 158 patients (80 males, 78 females) with ampullary (99) or non-ampullary (59) neoplasms were identified. Ampullary lesions exhibited advanced histology (dysplasia or carcinoma) in 64 cases (65%), were managed surgically in 56 cases (56%), and were managed endoscopically in 31 cases (31%), compard to non-ampullary lesions, which exhibited advanced histology in 25 cases (42%, p < 0.05), were managed surgically in 10 cases (17%, p < 0.01), and were managed endoscopically in 28 cases (47%, p < 0.01). In patients requiring surgery, lesions were ampullary in 57/67 (85%), exhibited advanced histology in 56/67 (79%), and had a mean size of 25.6 ± 7.3 mm, compared to patients undergoing endoscopic management in whom lesions were ampullary in 30/58 (52%, p < 0.01), exhibited advanced histology in 15/58 (26%, p < 0.01), and had a mean size of 18.4 ± 12.1 mm (p < 0.05). Whipple procedure accounted for 60/67 (90%) operations. Lesions with advanced histology were ampullary in 64/89 (61%), surgically managed in 49/89 (55%), endoscopically managed in 20/89 (22%), and had a mean size 27.4 ± 13.1 mm, compared to lesions with less advanced histology (tubular, tubulovillous, or villous adenomas) which were ampullary in 33/69 (49%, p < 0.01), surgically managed in 13/69 (19%, p < 0.01), endoscopically managed in 44/69 (64%, p < 0.01), and had a mean size of 17.7 ± 11.1 mm (p < 0.01). Summary: Ampullary neoplasms are more likely to contain advanced histology and be managed surgically, compared to non-ampullary neoplasms. Patients with duodenal neoplasms undergoing surgical intervention are more likely to have large, ampullary lesions with advanced histology, compared to patients managed endoscopically. Advanced lesions are more likely to be ampullary, larger, and require surgical management, compared to less advanced neoplasms. Conclusion: Duodenal neoplasms that were managed surgically were larger, more frequently ampullary, and exhibited more advanced histology, however, it is likely that with further advances in endoscopy, more of these lesions can be managed endoscopically.