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

Equipment

1. Gastroscope (diagnostic or therapeutic), duodenoscope, or pediatric colonoscope (preferably with high definition) as dictated by polyp location
2. Short transparent distal cap
3. Light source and image processor
4. Electrosurgical generator + pad
5. Endoscopic snare (hot or cold): size determined by target
6. Endoscopic biopsy forceps (hot or cold)
7. Argon plasma coagulation (APC) and appropriate processor
8. Sclerotherapy needle
9. Submucosal injectant (saline, hetastarch, colloid; low-viscosity emulsion (Eleview, Olympus America), viscous gel (ORISE, Boston Scientific); with or without epinephrine)
10. Dye—methylene blue, indigo carmine
11. Retrieval accessory: trap and/or retrieval net

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

Special Considerations

1. Polyps on duodenal sweep (anterior, medial wall) usually require a duodenoscope.
2. Duodenoscope challenges related to instrument manipulation through elevator.
3. Distal duodenal polyps may require a pediatric colonoscope to reach.
4. Identification of margins may be difficult due to villiform nature of both normal duodenal mucosa and adenomas—solution: dye or electronic chromoendoscopy.
5. Crevices/valleys may be challenging to lift and resect.
6. Limited room and maneuverability within the duodenal lumen may mean limitations to degree of lift and size of snares used for resection.

FIG. 17.2 A, Duodenal adenoma visualized with standard gastroscope. B, Margins of this duodenal adenoma better visualized using a standard gastroscope fitted with a clear cap. C, Resection site after lift with epinephrine and methylene blue and piecemeal resection with snare cautery.