Superficial Non-ampullary Duodenal Tumors Research Articles

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.

Usefulness of the S-O clip for duodenal endoscopic submucosal dissection: a propensity score-matched study.

Endoscopic submucosal dissection (ESD) for superficial non-ampullary duodenal tumors (SNADETs) is associated with a high rate of en bloc resection. However, the technique for ESD remains challenging. Recent studies have demonstrated the effectiveness of S-O clips in colonic and gastric ESD. We evaluated the efficacy and safety of duodenal ESD using an S-O clip for SNADETs. Consecutive patients who underwent ESD for SNADETs between January 2011 and December 2021 were retrospectively enrolled. Propensity score matching analysis was used to compare patients who underwent duodenal ESD with the S-O clip (S-O group) and those who underwent conventional ESD (control group). Intraoperative perforation rate was the primary outcome, while procedure time and R0 resection rate were the secondary outcomes. After propensity score matching, 16 pairs were created: 43 and 17 in the S-O and control groups, respectively. The intraoperative perforation rate in the S-O group was significantly lower than that in the control group (p=0.033). A significant difference was observed in the procedure time between the S-O and control groups (39±9 vs. 82±30 minutes, respectively; p=0.003). The S-O clip reduced the intraoperative perforation rate and procedure time, which may be useful and effective in duodenal ESD.

Laparoscopic and endoscopic combined surgery to treat a large superficial nonampullary duodenal tumor.

Endoscopic resection of large superficial nonampullary duodenal tumors is clinically challenging as the unique anatomical features of the duodenum (thin wall, narrow lumen, exposure to biliary and pancreatic fluids, and small operating space) increase the risks of intra- and post-procedural complications [1]. As conventional surgical methods of resecting superficial nonampullary duodenal tumors are associated with high morbidity and mortality [2], novel combined laparoscopic and endoscopic approaches have recently been developed in specialized centers in an attempt to overcome these limitations [3] [4].

Magnified endoscopy with texture and color enhanced imaging with indigo carmine for superficial nonampullary duodenal tumor: a pilot study

This pilot study aimed to investigate the utility of texture and color enhancement imaging (TXI) with magnified endoscopy (ME) for the preoperative diagnosis of superficial nonampullary duodenal epithelial tumors (SNADETs). We prospectively evaluated 12 SNADETs. The visibility for ME-TXI, ME with indigo carmine (ICME)—white-light imaging (WLI), ICME-TXI compared to ME-NBI (narrow-band imaging) was scored (+ 2 to − 2 ME-NBI was set as score 0) by 3 experts. Scores + 2 and + 1 were defined as improved visibility. The intra-observer and interobserver agreement for improved visibility of surface structure (SS) was evaluated. Sensitivity, specificity, and positive predictive value (PPV) for Vienna Classification (VCL) C4/5 associated with the preoperative diagnosis of ICME-TXI were analyzed. The SS visibility score of ICME-TXI was significantly higher than that of ME-NBI, ME-TXI, and ICME-WLI (P < 0.001 respectively). The kappa coefficients of reliability for intra-observer and interobserver agreement for the SS visibility improvement with ICME-TXI were 0.96, 1.00, 1.00 and 0.70, 0.96, 0.96 respectively. All endoscopists preferred ICME-TXI for visualizing SS mostly for all lesions. The sensitivity, specificity, and PPV (%) of ICME-TXI for VCL C4/5 were 80, 66.7, and 63.2, respectively. ICME-TXI facilitates the visibility of the SS of SNADETs and may contribute to their preoperative diagnosis.

Clinicopathological features and management strategy for superficial nonampullary duodenal tumors: a multi-center retrospective study.

PurposeWe investigated the clinicopathological features and management for superficial nonampullary duodenal tumors (SNADTs). The safety and feasibility of laparoscopic management, especially laparoscopic endoscopic cooperative surgery (LECS), were evaluated.MethodsA total of 59 patients with SNADTs who underwent operations from January 2009 to December 2018 at all 8 institutions of the Catholic Medical Center were identified in our comprehensive multi-institutional database. Clinicopathological and surgical data on the 4 anatomical regions of the duodenum were collected and compared. Characteristics of conventional laparoscopic procedure (laparoscopy-only) and LECS procedures were also compared.ResultsThere were significantly more asymptomatic patients with tumors in the first and second vs. third and fourth duodenal regions. Gastrointestinal stromal tumors (GISTs), carcinoids, and ectopic pancreatic tumors were identified in 32, 12, and 5 cases, respectively. Forty-two patients (71.2%) underwent laparoscopy. Of patients undergoing laparoscopy, the LECS group exhibited significantly more endophytic features and smaller tumor sizes (P < 0.001 and P < 0.001, respectively). Although no significant difference in the wedge resection or postoperative complication rate was seen between the 2 groups (P = 0.096 and P = 0.227, respectively), the wedge resection rate was higher, and the complication rate lower, in the LECS group than the conventional laparoscopic surgery group.ConclusionMost of the SNADTs located in proximal duodenum were detected incidentally. GISTs were the most common diagnoses of SNADTs in all locations. In treating these tumors, laparoscopic resection is safe and feasible. Especially, LECS may be ideal for treating small endophytic tumors, minimizing over-resection and postoperative complications.

Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline and Endoscopic management of superficial nonampullary duodenal tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline and Endoscopic management of superficial nonampullary duodenal tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Endoscopic Closure After Endoscopic Resection for Superficial Non-Ampullary Duodenal Tumors.

Endoscopic Closure After Endoscopic Resection for Superficial Non-Ampullary Duodenal Tumors.

Association between Endoscopic Milk-White Mucosa, Epithelial Intracellular Lipid Droplets, and Histological Grade of Superficial Non-Ampullary Duodenal Epithelial Tumors.

We previously reported that superficial non-ampullary duodenal tumors (SNADETs) commonly had a whitish mucosal surface, named milk-white mucosa (MWM). The aim of this study was to evaluate the association of MWM with epithelial intracellular lipid droplets (immunohistochemically stained by adipose differentiation-related protein (ADRP)) and histological tumor grades. We reviewed endoscopic images and the histopathology of SNADETs resected en bloc endoscopically. We analyzed the correlation between the positive rates of endoscopic MWM in preoperative endoscopy and resected specimens, and ADRP-positive rates in the resected specimens. Associations between the MWM-positive rates and tumor grades, high-grade intraepithelial neoplasia (HGIN)/intramucosal carcinoma (IC), and low-grade intraepithelial neoplasia (LGIN) were analyzed. All the 92 SNADETs analyzed were <20 mm and histologically classified into 39 HGIN/IC and 53 LGIN. Spearman’s rank correlation coefficient showed a significant correlation between MWM-positive and ADRP-positive rates (p < 0.001). MWM-positive rates were significantly lower in the HGIN/IC than in the LGIN in preoperative endoscopy (p < 0.001) and resected specimens (p = 0.02). Our results suggest that endoscopic MWM is closely associated with epithelial intracellular lipid droplets and that the MWM-positive rate may be a predictor of histological grade in small SNADETs.

The Use of Endoscopic Clipping in Preventing Delayed Complications after Endoscopic Resection for Superficial Non-Ampullary Duodenal Tumors.

Background/AimsEndoscopic resection (ER) has recently been accepted as the standard treatment modality for superficial non-ampullary duodenal tumors (SNADTs). However, the procedure can cause adverse events such as perforation and bleeding. This study aimed to investigate the efficacy of prophylactic clipping in the prevention of delayed complications. MethodsA retrospective review of the medical records of patients who underwent ER for SNADT from 3 centers was performed. Patients were divided into 2 groups: the immediate clipping group (ICG) and the no clipping group (NCG). Various baseline characteristics and factors associated with the appearance of delayed complications, such as size of the lesion, tumor location, histologic type, and co-morbidities, were compared between the two groups. ResultsA total of 99 lesions from 99 patients were included in this study. Fifty-two patients were allocated into ICG and 47 patients were allocated into NCG. Delayed bleeding occurred in 1 patient from ICG and in 8 patients from NCG. Delayed perforation occurred in 1 patient from ICG and in 3 patients from NCG. There were no procedure-related deaths in both groups. ConclusionsAlthough the use of endoscopic clipping seemed to reduce the risk of developing delayed complications, further studies using a prospective design is required.

Endoscopic and Clinicopathological Features of Superficial Non-Ampullary Duodenal Tumor Based on the Mucin Phenotypes

Aims: We aimed to clarify the endoscopic/clinicopathological features of superficial non-ampullary duodenal epithelial tumors (SNADETs) based on their mucin phenotypes. Methods: We analyzed 62 SNADET lesions and classified them based on mucin phenotypic expression. Endoscopic and clinicopathological findings were compared according to mucin phenotypes. Results: Eleven lesions had the gastric phenotype (GP) and 43 lesions had the intestinal phenotype (IP). All GP lesions were located in the first portion of the duodenum, while most IP lesions (72.1%) were located in the second portion (p < 0.01). Tumor size was significantly larger in the GP than in the IP group (14.4 mm vs. 10.2 mm, p < 0.05). Reddish color (72.7% in GP vs. 37.2% in IP, p < 0.05), type 0-I (72.7% vs. 11.6%, p < 0.01), lobular/granular pattern (81.8% vs. 4.7%, p < 0.01), and category 4/5 in Vienna classification (81.8% vs. 30.2%, p < 0.01) were observed significantly more often in the GP than in the IP group. Regarding findings of magnifying endoscopy with narrow-band imaging (M-NBI), white opaque substance (22.2% in GP vs. 89.7% in IP, p < 0.01) and light blue crest (0% vs. 43.6%, p < 0.05) were significantly less frequently observed in the GP group. Oval-shaped marginal epithelium (66.7% vs. 17.9%, p < 0.01), dense pattern (55.6% vs. 2.6%, p < 0.01), and dilatation of the intervening part (100% vs. 12.8%, p < 0.01) were more frequently observed in the GP group. Conclusions: SNADETs showed distinct endoscopic/clinicopathological features according to the mucin phenotype. Tumor location, coloration, macroscopic type, and endoscopic findings including M-NBI are useful to distinguish the mucin phenotypes of SNADETs.

Clinical outcomes of endoscopic resection for superficial non-ampullary duodenal tumors

Background and study aims Because superficial non-ampullary duodenal epithelial tumors (SNADETs) are relatively rare, studies evaluating the outcomes of endoscopic resection (ER) for SNADETs are limited. Therefore, this study aimed to evaluate the clinical validity of ER for SNADETs. Patients and methods The study participants included 163 consecutive patients (108 men; mean age, 61.5 ± 11.3 years) with 171 SNADETs, excluding patients with familial adenomatous polyposis resected by ER, at Hiroshima University Hospital between May 2005 and September 2016. Clinicopathological features and the outcomes of ER for 171 cases were retrospectively analyzed. Additionally, the prognosis of 135 patients with more than 12 months’ follow-up was analyzed. Results Mean diameter of SNADETs was 10.7 ± 7.2 mm. Most of the SNADET cases were classified as category 3 (71 %, 121/171), but some were category 5 (2 %, 3/171). En bloc resection rates were 93 % (146/157), 100 % (7/7), and 86 % (6/7) in endoscopic mucosal resection (EMR), polypectomy, and in endoscopic submucosal dissection (ESD) cases, respectively. Complete resection rates were 90 % (141/157), 100 % (7/7), and 71 % (5/7) in EMR, polypectomy, and ESD cases, respectively. Emergency surgery was performed in two patients with intraoperative perforation and in two with delayed perforation without artificial ulcer bed closure after ER. Since endoscopic closure of ulcer by clipping was performed, delayed perforation has not occurred. Local recurrence occurred in 1.2 %, but no metastasis to lymph nodes or other organs occurred after ER. No patient died of primary SNADETs. Conclusion Our data supported the clinical validity of ER for SNADETs. However, delayed perforation should be given much attention.

Endoscopic diagnosis and treatment of superficial non-ampullary duodenal tumors.

The diagnostic and treatment guidelines of superficial non-ampullary duodenal tumors have not been standardized due to their low prevalence. Previous reports suggested that a superficial adenocarcinoma (SAC) should be treated via local resection because of its low risk of lymph node metastasis, whereas a high-grade adenoma (HGA) should be resected because of its high risk of progression to adenocarcinoma. Therefore, pretreatment diagnosis of SAC or HGA is important to determine the appropriate treatment strategy. There are certain endoscopic features known to be associated with SAC or HGA, and current practice prioritizes the endoscopic and biopsy diagnosis of these conditions. Surgical treatment of these duodenal lesions is often related to high risk of morbidity, and therefore endoscopic resection has become increasingly common in recent years. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are the commonly performed endoscopic resection methods. EMR is preferred due to its lower risk of adverse events; however, it has a higher risk of recurrence than ESD. Recently, a new and safer endoscopic procedure that reduces adverse events from EMR or ESD has been reported.

An early superficial non-ampullary duodenal tumor cured with endoscopic submucosal dissection: A case report.

Early superficial non-ampullary duodenal tumors are particularly rare, the clinical manifestations, including typical endoscopic or imaging features, and treatment methods are not well-characterized. The present case report describes a case of an asymptomatic 74-year-old male who presented to the Taizhou People's Hospital (Taizhou, China) for a regular health screening, where a primary superficial non-ampullary duodenal tumor was identified. Upper endoscopy revealed ~1.2 cm lesion in the second portion of the duodenum. Chromoscopy and magnification endoscopy indicated an early cancer characteristic. Subsequent endoscopic submucosal dissection was performed to remove the lesion. Histopathology validated that the lesion was a high-grade intro-epithelial neoplasm without lymph node or blood vessel invasion.

Su1217 Patients Without Helicobacter Pylori Infection May Have a Potential Risk for Incidence of Superficial Non-Ampullary Duodenal Tumors: A Retrospective Analysis in 188 Cases

As development of endoscopic resection technique, superficial non-ampullary duodenal tumors (SNADETs), which are sometimes incidentally detected in patients without symptoms, have also become treatable endoscopically. However, clinicopathological characteristics of that tumor remain unknown. We speculate that the environment in the stomach particularly regarding Helicobacter Pylori (HP) infection and subsequent atrophic change of the gastric mucosa might influence on the tumorigenesis of SNADETs. To investigate the relationship between HP status and incidence of SNADETs, we retrospectively assessed atrophic change of the stomach in patients with SNADETs, followed by the comparison of these cases to historical controls.

Endoscopic Submucosal Dissection for Large Superficial Non-ampullary Duodenal Tumor: 2016 ACG Presidential Poster Award

Introduction: Endoscopic submucosal resection (ESD) is well established as a curable and safety procedure even for large superficial neoplasias of the stomach, esophagus and colon. However, duodenal ESD is technically challenging because of anatomical specificities and has not been accepted as a standard method of local resection to date. This study aimed to validate the feasibility and long-term outcomes of ESD applied to superficial nonampullary duodenal tumors (SNADT), larger than 20 mm, which are outside the indication for conventional EMR. Methods: 59 patients, with 59 large SNADTs, who underwent ESD between April 2005 to June 2016 were included in the study. The short- and long-term outcomes were retrospectively evaluated, related to tumor size, resection size, histological type, invasion depth, complete resection rate, operation time, perforation rate, delayed bleeding rate, local recurrence rate, distant metastasis, and survival rate. Results: The median sizes of tumors and resected specimens were, respectively, 25mm (range 20-70mm) and 35.0mm (range 22- 80mm). Histopathological findings showed 25 adenocarcinomas (23 mucosal, 2submucosal) and 34 adenomas (25 high grade dysplasia, 9 low grade dysplasia). The complete resection rate was 86.4% (51/59 tumors). The mean operation time was 153.3minutes. Perforation during ESD occurred in 13.6% (8/59) and delayed bleeding occurred in 10.2% (6/59). Among the cases with prophylactic closure of the mucosal defect, the delayed bleeding rate was decreased to 3.8% (1/26). Delayed perforation occurred the next day in 1 ESD patient without prophylactic closure, who required local closure and drainage of an abscess by open surgery 5 days after ESD. The median observation period was 59.7 months (range 0.7-131.1months), and no local recurrence or distant metastasis was seen during this time, representing a disease-free survival rate of 100%. Conclusion: ESD for large SNADT is feasible with favorable long-term outcomes. However, because of the high complication rate due to its technical difficulty, experience and skill of the operator are essential. And the prophylactic endoscopic closure of mucosal defects after ESD could prevent hazardous delayed complications.

Duodenal tubular resection using laparoscopic-endoscopic cooperative surgery: A new technique for the treatment of duodenal lesions.

Laparoscopic-endoscopic cooperative surgery (LECS) is a minimally invasive surgical technique that combines the advantages of laparoscopic surgery and endoscopic treatment. LECS has been developed for treatment of gastric submucosal tumors and can be applied to superficial non-ampullary duodenal tumors. Here we describe the use of LECS for duodenal mucosal cancer. After the placement of five ports, an endoscopic procedure was performed to confirm the tumor location and to place marks around the tumor. The jejunum was then resected 10 cm from the ligament of Treitz, and the connective tissue between the pancreas and duodenum was dissected to close to Vater's papilla. Duodenal resection was performed with a stapling device 2 cm to the oral side of the tumor, with endoscopic confirmation of the duodenal papilla, and duodenal tubular resection was then accomplished. Duodeno-jejunostomy was carried out using the same stapling device. There were no postoperative complications. This case shows that duodenal tubular resection using LECS enables curability through a minimally invasive procedure that offers the advantages of laparoscopic surgery and endoscopic treatment. This technique is applicable to duodenal lesions such as those due to duodenal mucosal cancers.