Management of endoscopically non-resectable duodenal polyps – update on the hamburg treatment pathway

Abstract

Purpose: Treatment of duodenal wall polyps is a multistep procedure with several therapeutic options. First line treatment is the endoscopic excision via Gastro-Duodenoscopy. However, large polyps are often not resectable by endoscopic approach only. In these cases surgical treatment is mandatory and pancreaticoduodenectomy (PD) a common choice of treatment. Pancreas preserving duodenectomy (total or partial) is a much less extensive alternative which good outcome. Preserving the pancreatic head does not only manage to maintain quality of life but also reduces postoperative morbidity due to pancreatic fistula. By preserving the normal anatomy, the pancreas preserving approach further allows normal endoscopic surveillance of proximal jejunum which is a major advantage as compared to the PD procedures. In suspected malignancy a step up approach is needed with PD as the treatment of choice. Methods: Between 1997 and 2020 24 patients with hereditary (n = 7) and non-hereditary (n = 17) duodenal wall polyps underwent PPD at the department of Surgery of the University Medical Center Hamburg-Eppendorf (UKE). Both groups are analysed retrospectively regarding differences of morbidity and mortality according to the Clavien-Dindo classification. Results: No statistical significant differences regarding morbidity and mortality were seen in both groups. In three patients of non-hereditary group compared to one patient of the hereditary group final histology revealed malignancy. One patient underwent surgery after endoscopical partial resection of a duodenal poly with transition into adenocarcinoma. However, during surgery no further malignant cells were found and pancreas preserving duodenctomy could be performed. Conclusions: There is a trend towards malignancy in patients with non-hereditary duodenal wall polyps, despite the extensive preoperative workup with repeated gastro-duodenoscopies. Thus patients with non hereditary duodenal-wall polyps should be monitored closely and endoscopical resection performed if possible. In case of malignancy after endoscopical resection we recommend a surgical step up approach with intraoperative pathological review of resection borders as pancreas preserving duodenectomy might still be an option. To facilitate therapeutic decisions and to optimize treatment results we updated our treatment pathway, which merges genetic, clinical and pathological data.