Superficial Non-ampullary Duodenal Epithelial Tumors Research Articles

Endoscopic diagnosis of epithelial subtypes of superficial non-ampullary duodenal epithelial tumors using magnifying narrow-band imaging.

Superficial non-ampullary duodenal epithelial tumors (SNADETs) include low-grade adenoma (LGA) and high-grade adenoma or carcinoma (HGA/Ca), and are classified into two different epithelial subtypes, gastric-type (G-type) and intestinal-type (I-type). We attempted to distinguish them by endoscopic characteristics including magnifying endoscopy with narrow-band imaging (M-NBI). Various endoscopic and M-NBI findings of 286 SNADETs were retrospectively reviewed and compared between G- and I-types and histological grades. M-NBI findings were divided into four patterns based on the following vascular patterns; absent, network, intrastructural vascular (ISV), and unclassified. Lesions displaying a single pattern were classified as mono-pattern and those displaying multiple patterns as mixed-pattern. Lesions showing CDX2 positivity were categorized as I-types and those showing MUC5AC or MUC6 positivity were categorized as G-types based on immunohistochemistry. Among 286 lesions, 23 (8%) were G-type and 243 (85%) were I-type. More G-type lesions were located oral to papilla (91.3％ vs 45.6％, P<0.001), and had protruding morphology compared to those of I-types (65.2% vs 14.4%, P<0.001). The major M-NBI pattern was ISV in G-type (78.2% vs 26.3％, P<0.001), and absent for I-type (0% vs 34.5%, P=0.003). Three endoscopic characteristics; location oral to papilla, protruding morphology and major M-NBI pattern (ISV) were independent predictors for G-type. Mixed-pattern was more common in HGA/Ca than LGA for I-type (77.0% vs 58.8%, P＝0.01); however, there was no difference for those in G-type. Endoscopic findings including M-NBI is useful to differentiate epithelial subtypes.

Underwater EMR versus conventional EMR for superficial non-ampullary duodenal epithelial tumors in the Western setting

Background and aimsConventional endoscopic mucosal resection (C-EMR) is established as the primary treatment modality for superficial non-ampullary duodenal epithelial tumors (SNADETs) but recently underwater EMR (U-EMR) emerged as a potential alternative. The majority of previous studies focused on Asian populations and small lesions (≤20 mm). We aimed to compare the efficacy and outcomes of U-EMR versus C-EMR for SNADETs in a Western setting. MethodsThis was a retrospective multinational study from 10 European centers that performed both C-EMR and U-EMR between January 2013 and July 2023. The main outcomes were the technical success, procedure-related adverse events (AEs), and the residual/recurrent adenoma (RRA) rate, evaluated on a per-lesion basis. We assessed the association between the type of EMR and the occurrence of AEs or RRA using mixed-effects logistic regression models (propensity scores). Sensitivity analyses were performed for lesions ≤ or >20 mm. ResultsA total of 290 SNADETs submitted to endoscopic resection during the study period met the inclusion criteria and were analyzed (C-EMR n=201, 69.3%; U-EMR n=89, 30.7%). Overall technical success rate was 95.5% and comparable between groups. In logistic regression models, compared with U-EMR, C-EMR was associated with a significantly higher frequency of overall delayed AEs (OR 4.95; 95%CI=2.87-8.53), post-procedural bleeding (OR=7.92; 95%CI=3.95-15.89) and RRA (OR=3.66; 95%CI=2.49-5.37). Sensitivity analyses confirmed these results when solely considering either small (≤20 mm) or large (>20 mm) lesions. ConclusionCompared with C-EMR, U-EMR was associated with a lower rate of overall AEs and RRA, regardless of lesion size. Our results confirm the possible role of U-EMR as an effective and safe technique in the management of SNADETs.

A first-in-human clinical study of laparoscopic autologous myoblast sheet transplantation to prevent delayed perforation after duodenal endoscopic mucosal dissection

BackgroundThe detection rate of superficial non-ampullary duodenal epithelial tumors (SNADETs) has recently been increasing. Large tumors may contain malignant lesions and early therapeutic intervention is recommended. Endoscopic mucosal dissection (ESD) is considered a feasible treatment modality, however, the anatomical and physiological characteristics of the duodenum create a risk of postoperative perforation after ESD.MethodsTo explore whether myoblast sheet transplantation could prevent delayed perforation after ESD, a first-in-human (FIH) clinical trial of laparoscopic autologous myoblast sheet transplantation after duodenal ESD was launched. Autologous myoblast sheets fabricated from muscle tissue obtained seven weeks before ESD were transplanted laparoscopically onto the serous side of the ESD. The primary endpoints were the onset of peritonitis due to delayed perforation within three days after surgery and all adverse events during the follow-up period.ResultsThree patients with SNADETs ≥ 20 mm in size underwent transplantation of a myoblast sheet onto the serous side of the duodenum after ESD. In case 1, The patient’s postoperative course was uneventful. Endoscopy and abdominal computed tomography revealed no signs of delayed perforation. Despite incomplete mucosal closure in case 2, and multiple micro perforations during ESD in case 3, cell sheet transplantation could prevent the postoperative massive perforation after ESD, and endoscopy on day 49 after transplantation revealed no stenosis.ConclusionsThis clinical trial showed the safety, efficacy, and procedural operability of this novel regenerative medicine approach involving transplanting an autologous myoblast sheet laparoscopically onto the serosa after ESD in cases with a high risk of delayed perforation. This result indicates the potential application of cell sheet medicine in treating various abdominal organs and conditions with minimal invasiveness in the future.Trial registrationjRCT, jRCT2073210094. Registered November 8 2021,https://jrct.niph.go.jp/latest-detail/jRCT2073210094.

Short- and long-term outcomes of endoscopic submucosal dissection and laparoscopic and endoscopic cooperative surgery for superficial non-ampullary duodenal epithelial tumors.

This retrospective study aimed to compare the short- and long-term outcomes of endoscopic submucosal dissection and laparoscopic and endoscopic cooperative surgery in patients with superficial non-ampullary duodenal epithelial tumors. We investigated consecutive patients with SNADETs > 10mm in size who underwent ESD (ESD group) or LECS (LECS group) between January 2015 and March 2021. The data was used to analyze the clinical course, management, survival status, and recurrence between the two groups. A total of 113 patients (100 and 13 in the ESD and LECS groups, respectively) were investigated. The rates of en bloc resection and curative resection were 100% vs. 100% and 93.0% vs. 77.0% in the ESD and LECS groups, respectively, with no significant difference. The ESD group had shorter resection and suturing times than the LECS group, but there were no significant difference after propensity score matching. There were also no differences in the rates of postoperative adverse event (7.0% vs. 23.1%; P = 0.161). The 3-year overall survival (OS) rate was high in both the ESD and LECS groups (97.6% vs. 100%; P = 0.334). One patient in the ESD group experienced recurrence due to liver metastasis; however, no deaths related to SNADETs were observed. ESD and LECS are both acceptable treatments for SNADETs in terms of a high OS rate and a low long-term recurrence rate, thereby achieving a comparable high rate of curative resection. Further studies are necessary to compare the outcomes of ESD and LECS for SNADETs once both techniques are developed further.

Safety of Duodenal Endoscopic Submucosal Dissection for Superficial Non-Ampullary Duodenal Epithelial Tumor: A Single-Center Study in the United States.

Endoscopic submucosal dissection (ESD) of superficial non-ampullary duodenal epithelial tumors (SNADETs) is associated with a high rate of en bloc resection and low rate of recurrence. However, in the United States, SNADETs are predominantly managed using endoscopic mucosal resection (EMR) or surgery because the feasibility and safety of duodenal ESD have not yet been established. In this study, we analyzed the outcomes of duodenal ESD for SNADETs. This single-center retrospective study reviewed the data of patients who underwent ESD for SNADETs between June 2018 and August 2023. Baseline patient characteristics, histopathology of the resected lesions, adverse events, and recurrence rates were evaluated. The primary outcome measures were en bloc resection, complications, and recurrence rate. Thirty ESD procedures were performed on 24 patients. All 30 lesions were adenomas, with no cancerous lesions. The en bloc resection rate and R0 resection rates were both 53%. There were no cases of procedure-associated perforation. Post-ESD bleeding was observed in six cases. No ESD-related mortality was observed. The recurrence rate was 14% in 1 year follow up, and 28% the during all follow-up period. ESD is a safe option for SNADET in the United States; however further comparative studies are necessary to determine the optimal procedure for North American populations.

Resectability of Small Duodenal Tumors: A Randomized Controlled Trial Comparing Underwater Endoscopic Mucosal Resection and Cold Snare Polypectomy.

Underwater endoscopic mucosal resection (UEMR) and cold snare polypectomy (CSP) are novel endoscopic procedures for superficial nonampullary duodenal epithelial tumors (SNADET). However, consensus on how to use both procedures appropriately has not been established. In this study, we evaluated treatment outcomes of both procedures, including resectability. In this single-center randomized controlled study conducted between January 2020 and June 2022, patients with SNADET ≤12 mm were randomly allocated to UEMR and CSP groups. The primary end point was sufficient vertical R0 resection (SVR0), which was defined as R0 resection including a sufficient submucosal layer. We compared treatment outcomes including SVR0 rate between groups. The SVR0 rate was significantly higher in the UEMR group than in the CSP group (65.6% vs 41.5%, P = 0.01). By contrast, the R0 resection rate was not significantly different between study groups (70.3% vs 61.5%, P = 0.29). The submucosal layer thickness was significantly greater in the UEMR group than in the CSP group (median 546 [range, 309-833] μm vs 69 [0-295] μm, P < 0.01). CSP had a shorter total procedure time (median 12 [range, 8-16] min vs 1 [1-3] min, P < 0.01) and fewer total bleeding events (9.4% vs 1.5%, P = 0.06). UEMR has superior vertical resectability compared with CSP, but CSP has a shorter procedure time and fewer bleeding events. Although CSP is preferable for most small SNADET, UEMR should be selected for lesions that cannot be definitively diagnosed as mucosal low-grade neoplasias.

Can underwater endoscopic mucosal resection be an alternative to conventional endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumors?

Underwater endoscopic mucosal resection (UEMR) is a simpler procedure for superficial non-ampullary duodenal epithelial tumors (SNADET) than conventional endoscopic mucosal resection (cEMR). This study aimed to evaluate whether cEMR can be substituted by UEMR for SNADET in terms of effectiveness, safety, and learning curve. A total of 157 consecutive patients with 203 SNADETs ≤20mm in diameter, including 107 lesions resected by cEMR and 96 lesions resected by UEMR, between January 2019 and May 2023, were retrospectively recruited. The treatment outcomes were compared between the cEMR and UEMR groups. The risk factors for incomplete resection by UEMR were analyzed using univariate and multivariate analyses. Lesions in the UEMR group were divided chronologically into five periods; thereafter, the en bloc resection rate and procedure time were compared. No significant differences existed between the cEMR and UEMR groups in the mean procedure time (3.9min vs. 3.6min, p=0.1380) or en bloc resection rate (91% vs. 94%, p=0.4138). No perforation was observed in either group. Tumor size was an independent risk factor for incomplete resection using UEMR (p<0.01). The history of biopsy was not associated with incomplete resection using UEMR. The en bloc resection rate of UEMR was 100% (20/20) in the first period and ranged from 90% to 100% over all periods. UEMR is safe and effective for SNADET ≤20mm, regardless of a history of biopsy, and is easy to learn. Thus, UEMR can serve as an alternative to cEMR.

Salvage treatment for local recurrence after endoscopic resection for superficial nonampullary duodenal epithelial tumors

Background and AimsLocal recurrence is a significant concern in endoscopic resection of superficial nonampullary duodenal tumors (SNADTs). Our objective was to elucidate the clinical outcomes of salvage endoscopic treatment. MethodsThis retrospective study included consecutive patients who underwent endoscopic resection of SNADTs between January 2013 and December 2021. Four hundred thirty-three patients were observed, excluding those with familial adenomatous polyposis and those who did not undergo surveillance endoscopy. Local recurrence was defined as histologically proven adenoma or adenocarcinoma in contact with a prior endoscopic resection scar. The clinicopathological characteristics of patients with local recurrence and outcomes of salvage endoscopic treatment were evaluated. ResultsLocal recurrence occurred in 33 (8%) of the 433 patients after endoscopic resection for SNADT. Multivariate analysis identified older age (≥63 years), larger lesion size (≥13 mm), and piecemeal resection as significant independent predictors of local recurrence. Among the 33 patients with 33 recurrent lesions, 10 lesions (30%) disappeared after forceps biopsy. Three patients (9%) remained untreated. Sixteen lesions (48%) disappeared after one session of salvage endoscopic treatment, and four lesions (12%) disappeared after two sessions of treatment. Among these 24 treatment sessions, underwater endoscopic mucosal resection was performed in 19 sessions. The median post-procedural hospitalization period was four days (interquartile range, 3–4.25 days). Delayed bleeding occurred in three sessions. No recurrences have been detected in the 30 salvaged patients. The median recurrence-free survival time was 24.5 months (interquartile range, 14–48.75 months). ConclusionsLocal recurrence after endoscopic resection of SNADT can be managed endoscopically.

Underwater Endoscopic Mucosal Resection Versus Conventional Endoscopic Mucosal Resection for Superficial Non-ampullary Duodenal Epithelial Tumors ≤20mm: A Systematic Review With Meta-analysis.

Underwater endoscopic mucosal resection (UEMR) is increasingly applied in the treatment of superficial non-ampullary duodenal epithelial tumors (SNADETs). This meta-analysis aimed to assess the efficacy and safety of UEMR for SNADETs ≤20mm in comparison with conventional endoscopic mucosal resection (CEMR). The following electronic databases were searched from 2012 until November 20, 2021: PubMed, Embase, Scopus, Web of Science databases, and Cochrane Library. The primary outcomes were the rates of en bloc resection and complete (R0) resection, and the secondary outcomes were procedure time, adverse events (delayed bleeding and delayed perforation), and recurrence rate. A total of 6 studies with 679 lesions (331 underwent UEMR and 348 CEMR) were included in this study. The pooled analysis showed that UMER achieves a similar en bloc resection rate (87.6 vs. 89.9%; odds ratio [OR], 1.29; 95% confidence interval [CI], 0.45 to 3.73; P =0.64; I2 =74%), a similar R0 resection rate (67.3 vs. 73.6%; OR, 1.11; 95% CI, 0.55 to 2.23; P =0.78; I2 =59%), a shorter procedure time (min) (mean difference [MD], -4.05, 95% CI: -6.40 to -1.71; P =0.0007; I2 =70%) compared with CEMR. There were no significant differences in the rates of delayed bleeding, delayed perforation, and recurrence (2.4 vs. 1.7%, 0 vs. 0.6%, 2.2 vs. 4.4%, respectively). This meta-analysis demonstrated that UEMR appears to be an effective and safe alternative to CEMR for SNADETs ≤20mm.

Endoscopic diagnosis and treatment of superficial non-ampullary duodenal epithelial tumors: A review.

The surface of the small bowel mucosa is covered more than any other section of the digestive canal; however, the overall prevalence of small bowel tumors of the whole gastrointestinal tract is evidently low. Owing to the improvement in endoscopic techniques, the prevalence of small bowel tumors has increased across multiple countries, which is mainly due to an increase in duodenal tumors. Superficial non-ampullary duodenal epithelial tumors (SNADETs) are defined as tumors originating from the non-ampullary region in the duodenum that share similarities and discrepancies with their gastric and colorectal counterparts in the pathogenesis and clinicopathologic characteristics. To date, white light endoscopy (WLE) remains the cornerstone of endoscopic diagnosis for SNADETs. Besides, narrow-band imaging (NBI) techniques and magnifying endoscopy (ME) have been widely used in the clinic and endorsed by multiple guidelines and consensuses for SNADETs' evaluation. Confocal laser endomicroscopy (CLE), endocytoscopy (ECS), and artificial intelligence (AI) are also up-and-coming methods, showing an exceptional value in the diagnosis of SNADETs. Similar to the endoscopic treatment for colorectal polyps, the choices for SNADETs mainly include cold snare polypectomy (CSP), endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and laparoscopic endoscopic cooperative surgery (LECS). However, owing to the narrow lumen, rich vascularity, weak muscle layer, abundant Brunner's gland, and the hardship of endoscope control, the duodenum ranks as one of the most dangerous operating areas in the digestive tract. Therefore, endoscopists must anticipate the difficulties in endoscopic maneuverability, remain aware of the increased risk of complications, and then select the appropriate treatment according to the advantages and disadvantages of each method.

Partial duodenectomy with seromyotomy by the "lift-and-cut" method for superficial nonampullary duodenal epithelial tumors: A novel technique.

The therapeutic strategy for superficial nonampullary duodenal epithelial tumors remains controversial. We developed a novel surgical technique for superficial nonampullary duodenal epithelial tumors. We report the initial two cases managed with this method. We endoscopically confirmed the tumor location and circumferentially incised the seromuscular layer of the duodenum along it. After circumferential seromyotomy, the submucosal layer was expanded by endoscopic insufflation, and the target lesion was sufficiently lifted. The submucosal layer, including the target lesion, was stapled and resected after confirming the absence of problems with endoscopic passage. The seromuscular layer was continuously sutured to bury and reinforce the stapler line. Single-incision laparoscopic surgery was performed in one case. The resected specimens measured 52 × 32 mm and 50 × 26 mm with negative surgical margins. Both patients were discharged without complications and demonstrated no evidence of stenosis. Compared with previously reported procedures, this method of partial duodenectomy with seromyotomy for superficial nonampullary duodenal epithelial tumors is promising, simple, and safe.

Superficial non-ampullary duodenal epithelial tumors now: endoscopic diagnosis and therapy.

With the recent increase in the frequency of duodenal tumor detection, significant progress has been made in endoscopic diagnosis and treatment. Although the first guidelines were issued in Japan, patient treatment varies widely among institutions. There is a need for improving the quality of endoscopic diagnosis and more curative and safer treatments. Biopsy is the standard diagnostic method; however, the diagnostic accuracy of endoscopic biopsy is not so high. Therefore, the differentiation of superficial non-ampullary duodenal epithelial tumors from non-neoplastic lesions is being developed. The incidence of lymph node and distant metastases of duodenal epithelial tumors is extremely rare in intramucosal carcinomas, and they are considered good candidates for endoscopic treatment if the technical difficulties can be resolved. Adverse events associated with endoscopic treatment are greatly reduced at advanced facilities through novel resection and closure methods, and further improvements are expected in the future. Clarifying the risk of metastatic recurrence may lead to the development of more appropriate treatments and curative resection criteria.

Underwater versus conventional endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumors ≤20mm: A systematic review and meta-analysis.

Underwater endoscopic mucosal resection (UEMR) is an emerging technique for endoscopic resection of superficial non-ampullary duodenal epithelial tumors (SNADETs). However, compared to conventional EMR, its efficacy and safety has not been widely explored. We conducted a comprehensive search using the Pubmed, Embase, and Cochrane Library databases to identify studies comparing the efficacy and safety of UEMR versus EMR for SNADETs. The main outcomes examined included en bloc resection rate, R0 resection rate, recurrence rate, procedure time, and adverse events. A total of 5 studies comprising 635 patients were included. All the literature included duodenal lesions smaller than 20mm. The pooled analysis showed that UEMR could achieve a higher en bloc resection rate (OR 1.78, 95%CI: 1.17 to 2.71, P=0.007) and shorter procedure time (MD -4.08, 95%CI: -6.44 to -1.73, P=0.0007) than EMR. However, the pooled results did not support a superiority of UEMR over EMR for R0 resection rate (OR 1.27; 95% CI: 0.90 to 1.81, P=0.18) or recurrence rate (OR 0.49; 95% CI: 0.15 to 1.67, P=0.26). The occurrence of adverse events, including postoperative bleeding, intraoperative perforation, and delayed perforation, was very low in included studies. Compared to EMR, UEMR is an effective and safe technique for SNADETs ≤20mm.

Quantitative diagnostic algorithm using endocytoscopy for superficial nonampullary duodenal epithelial tumors.

Optical biopsy using endocytoscopy for superficial nonampullary duodenal epithelial tumors (SNADETs) is practical; however, a diagnostic algorithm has not been established. The aim of this study was to determine correlations of endocytoscopic findings of SNADETs with histology using computer analysis and to establish an algorithm. Endocytoscopic images and histological images of duodenal lesions from 70 patients were retrospectively collected. The numbers of glands and densely stained areas with methylene blue (DSMs) per 1mm2 and the percentage of DSMs per screen in endocytoscopy were determined. Moreover, correlations in DSMs and glands between endocytoscopy and histological images were analyzed. Histopathological diagnoses were assessed according to the revised Vienna classification. The primary outcome was correlation between the number of glands in endocytoscopy and that in histology. Finally, a diagnostic algorithm for endoscopic intervention of SNADETs with a statistical program command was established. The number of glands in endocytoscopic images was correlated with that in histopathological images (ρ 0.64, P<0.001). There were significant differences in the mean number of glands between category 4/5 and category 3 (P=0.03) and the mean percentage of DSMs between category 4/5 and category 1 (P<0.001). When the cutoffs for the number of glands and percentage of DSMs were set at 47 per 1mm2 and 20.8% in one screen, respectively, the area under the ROC curve was 0.89. Endocytoscopic images of SNADETs reflect histopathological atypia, and computer analysis provides a practical diagnostic algorithm for endoscopic intervention.

Current status and perspectives for endoscopic diagnosis of superficial nonampullary duodenal epithelial tumors.

In recent years, there have been significant advances in the endoscopic resection (ER) procedures of superficial nonampullary duodenal epithelial tumors (SNADETs). A preoperative endoscopic diagnosis is thus deemed necessary in determining the indication for subsequent ER. For the histologic and endoscopic diagnosis of SNADETs, understanding the mucin phenotype is inevitable. Recently, two diagnostic algorithms for the differential diagnosis of SNADETs from nonneoplastic lesions under magnifying endoscopy with narrow-band imaging have been proposed. In addition, various endoscopic approaches have been proposed to differentiate low- and high-grade adenomas/carcinomas, including white light endoscopy, magnifying image-enhanced endoscopy, and endocytoscopy. These methods, however, have not been standardized with respect to the classification of their findings and the validation of their diagnostic accuracy. Moreover, there are still concerns with respect to the histologic criteria required to establish a SNADETs diagnosis. Standardization in the histologic and endoscopic diagnosis of SNADETs is needed.

‘Underwater endoscopic mucosal resection with submucosal injection and marking’ for superficial non-ampullary duodenal epithelial tumors to achieve R0 resection: a single-center case series

Objectives To describe an endoscopic technique named ‘underwater endoscopic mucosal resection (UEMR) with submucosal injection and marking (UEMR-SIM)’ and to evaluate the therapeutic characteristics of superficial non-ampullary duodenal epithelial tumors (SNADETs) < 20 mm vis-a-vis classical EMR (CEMR) and UEMR techniques. Materials and methods This retrospective study included 103 consecutive SNADET patients (103 lesions) who underwent CEMR, UEMR, or UEMR-SIM. The UEMR-SIM procedure included (1) marking and submucosal injection, (2) filling of the duodenal lumen with 0.9% saline, (3) snaring of the lesion, and (4) electrosurgical removal. The procedural outcomes were compared between the UEMR-SIM and other-procedure groups. Results The en bloc resection rate was significantly higher in the UEMR-SIM group (100%) than in the CEMR group (76.8%) (p = 0.015) but was not statistically different between the UEMR-SIM and UEMR groups (88.0%) (p = 0.236). The R0 resection rate was significantly higher in the UEMR-SIM group (90.9%) than in the UEMR group (48.0%) (p = 0.001) but was not statistically different between the UEMR-SIM and CEMR groups (76.8%) (p = 0.209). Conclusions Our study indicates that the proposed method, UEMR-SIM for SNADETs, is feasible to achieve a high R0 resection rate and a potentially low local recurrence rate.

Non-atrophic gastric mucosa is an independently associated factor for superficial non-ampullary duodenal epithelial tumors: a multicenter, matched, case-control study.

The etiology of superficial non-ampullary duodenal epithelial tumors (SNADETs) remains unclear. Recent studies have reported conflicting associations between duodenal tumor development and Helicobacter pylori infection or endoscopic gastric mucosal atrophy. As such, the present study aimed to clarify the relationship between SNADETs and H. pylori infection and/or endoscopic gastric mucosal atrophy. This retrospective case-control study reviewed data from 177 consecutive patients with SNADETs who underwent endoscopic or surgical resection at seven institutions in Japan over a three-year period. The prevalence of endoscopic gastric mucosal atrophy and the status of H. pylori infection were compared in 531 sex- and age-matched controls selected from screening endoscopies at two of the seven participating institutions. For H. pylori infection, 85 of 177 (48.0%) patients exhibited SNADETs and 112 of 531 (21.1%) control patients were non-infected (p<0.001). Non-atrophic mucosa (C0 to C1) was observed in 96 of 177 (54.2%) patients with SNADETs and 112 of 531 (21.1%) control patients (p<0.001). Conditional logistic regression analysis revealed that non-atrophic gastric mucosa was an independent risk factor for SNADETs (odds ratio, 5.10; 95% confidence interval, 2.44-8.40; p<0.001). Non-atrophic gastric mucosa, regardless of H. pylori infection status, was a factor independently associated with SNADETs.

Underwater Versus Conventional Endoscopic Mucosal Resection for Superficial Non-ampullary Duodenal Epithelial Tumors: A Systematic Review and Meta-Analysis.

Duodenal underwater endoscopic mucosal resection (UEMR) has been suggested as a feasible treatment option for superficial non-ampullary duodenal epithelial tumors (SNADETs). However, its efficacy and safety have not been fully established yet. Thus, the objective of this systematic review and meta-analysis was to determine the efficacy and safety of UEMR as compared with conventional endoscopic mucosal resection (CEMR) in the treatment of SNADETs. We conducted a comprehensive literature search in PubMed, EMBASE, the Cochrane Library. Studies comparing CEMR and UEMR for the resection of SNADET were included. Outcomes included en-bloc and complete resection rates, adverse events, and procedure time. A total of six studies with 2454 lesions were included in the quantitative synthesis. En-bloc and complete resection rates were not significantly different between UEMR and CEMR (OR for en-bloc resection: 0.997 [95% CI 0.439-2.266]; OR for complete resection: 0.960 [95% CI 0.628-1.468]). There was no significant risk difference for perforation (risk difference: - 0.002; 95% CI - 0.009 to 0.005) or delayed bleeding (risk difference: - 0.001; 95% CI - 0.014 to 0.011). Procedure time was significantly shorter in the UEMR (standardized mean difference: - 1.294; 95% CI - 2.461 to - 0.127). The risk of recurrence was not significantly different between UEMR and CEMR (risk difference: 0.001; 95% CI - 0.041 to 0.044). Although our results did not show any superiority of UEMR over CEMR in the treatment of SNADETs, UEMR showed equivalent efficacy and safety as compared with CEMR and was associated with a shorter procedure time.

Magnifying Narrow-Band Imaging with Acetic Acid Spray for Superficial Non-Ampullary Duodenal Epithelial Tumors Based on the Mucin Phenotype

Introduction: This study aimed to identify the characteristics of superficial non-ampullary duodenal epithelial tumors (SNADETs) based on the mucin phenotype using magnifying narrow-band imaging with acetic acid spray (MA-NBI) and evaluate the efficacy of MA-NBI in differentiating gastric-type (G-type) from intestinal-type (I-type) lesions. Methods: We retrospectively identified 59 resected SNADETs in 59 patients who underwent MA-NBI. We evaluated surface patterns using MA-NBI to differentiate G-type from I-type lesions. Surface structures were classified into three patterns: tubular, villous, or oval structures. Lesions displaying a single pattern among the three patterns were classified as monotype, whereas those displaying multiple surface patterns were classified as mixed type. In addition, lesions with disorganized and unclear structures with irregular margins were classified as irregular surface structures. Results: In total, 32 (54%), 26 (44%), and 1 (2%) lesions were classified as Vienna category 3, 4, and 5 tumors, respectively, whereas 49 (83%) and 10 (17%) were classified as I- and G-type lesions, respectively. Oval structures were more frequently observed in G-type lesions (70%), whereas tubular structures were more frequently observed in I-type lesions (78%) (p < 0.001). Category 4 and 5 lesions had significantly higher mixed and irregular surface structure rates than category 3 lesions (41 vs. 6%, p = 0.003 and 81 vs. 3%, p < 0.001, respectively). Conclusion: MA-NBI can distinguish the mucin phenotypes of SNADETs and may facilitate histological grade diagnosis.

A feasibility study comparing gel immersion endoscopic resection and underwater endoscopic mucosal resection for superficial nonampullary duodenal epithelial tumors.

Although gel immersion endoscopic resection (GIER) is a potential alternative to underwater endoscopic mucosal resection (UEMR) for superficial nonampullary duodenal epithelial tumors (SNADETs), comparisons between the two are currently insufficient. 40 consecutive procedures performed in 35 patients were retrospectively reviewed; the primary outcome was procedure time, and the secondary outcomes were en bloc and R0 resection rates, tumor and specimen size, and adverse events. Lesions were divided into GIER (n = 22) and UEMR groups (n = 18). The median (range) procedure time was significantly shorter in the GIER group than in the UEMR group (2.75 [1-3.5] minutes vs. 3 2 3 4 5 6 7 8 9 10 minutes; P = 0.01). The en bloc resection rate was 100 % in the GIER group, but only 83.3 % in the UEMR group. The R0 resection rate was significantly higher in the GIER group than in the UEMR group (95.5 % vs. 66.7 %; P = 0.03). The median specimen size was larger in the GIER group than in the UEMR group (14 mm vs. 7.5 mm; P < 0.001). The tumor size was not significantly different between the groups and no adverse events were observed. GIER is efficacious and safe to treat SNADETs, although additional studies are needed.