Endoscopic Mucosal Resection of Duodenal Lesions



Endoscopic Mucosal Resection of Duodenal Lesions


Richard S. Kwon, MD, MS



This chapter will focus on duodenal adenomas which can present an endoscopic challenge. The prevalence of sporadic duodenal adenomas is roughly 5% of patients undergoing esophagogastroduodenoscopy (EGD)1 and up to 90% in familial adenomatous polyposis (FAP) syndrome.2 Sporadic ampullary adenomas are much rarer with a 0.12% prevalence.3

The treatment of choice for duodenal adenomas is endoscopic resection. The therapeutic goal is to resect these precancerous lesions before malignant degeneration, as well as, to avoid more invasive surgical resection. However, clinical decisions require consideration of the patient’s comorbidities, age, preferences, and the relative risks of adverse events and malignancy.


NONAMPULLARY DUODENAL ADENOMAS


Preparation



  • 1. NPO at least 6 hours prior


  • 2. ASGE guidelines for antithrombotics, antiplatelets, and anticoagulation.4 Discuss with appropriate healthcare providers


  • 3. Preprocedure labs usually not necessary


  • 4. Left lateral position


  • 5. Sedation (anesthesia, monitored anesthesia, or conscious sedation) depending on comorbidities and availability of anesthesia services


  • 6. Cardiopulmonary monitoring



Endoscopic Evaluation



  • 1. Appropriate endoscope (may require multiple scopes, use of transparent distal cap)


  • 2. White light or electronic chromoendoscopy or dye-based chromoendoscopy


  • 3. Endoscopic considerations: evidence of submucosal invasion or malignancy, as well as, risks of incomplete/unsuccessful resection



    • a. Size


    • b. Percentage of lumen circumference (see Fig. 17.1)


    • c. Length


    • d. Relationship to the ampulla


    • e. Location within the duodenal sweep


    • f. Scar or fibrosis from prior resection attempts or nonlifting on submucosal injection


    • g. Mucosal assessment for risk of dysplasia



      • i. Paris classification5


      • ii. Kudo pit pattern6


      • iii. Spigelman criteria (for familial polyposis syndromes)7






FIG. 17.1 Duodenal adenoma occupying ˜75% of the circumference of the lumen and deemed endoscopically unresectable.



Methods of Duodenal Adenoma Resection



  • 1. Conventional polypectomy


  • 2. Endoscopic mucosal resection (with submucosal injection)8 (see Fig. 17.2)


  • 3. Underwater resection3,9


  • 4. Band and slough10


  • 5. Endoscopic submucosal dissection (should be reserved for expert endoscopists)11




May 29, 2020 | Posted by in GASTROENTEROLOGY | Comments Off on Endoscopic Mucosal Resection of Duodenal Lesions
Premium Wordpress Themes by UFO Themes