Endoscopic and surgical management of nonampullary duodenal neoplasms
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Sporadic nonampullary duodenal neoplasms (SNADN) can have malignant potential for which endoscopic and surgical resections are offered. We report combined gastroenterologic and surgical experience for treatment of SNADN, including endoscopic mucosal resection (EMR) and pancreas-preserving partial duodenectomy (PPPD).
We retrospectively reviewed 121 consecutive patients, who underwent 30 PPPDs and 91 EMRs for mucosal and submucosal SNADN. Decision to undergo EMR or surgical resection was based on expert endoscopist and surgeon discretion including multidisciplinary tumor board review. Main outcomes were recurrence rate of neoplasia and adverse events requiring hospital admission or prolonged care. EMRs were performed with submucosal lifting followed by snare resection. PPPD included total duodenectomy, supra-ampullary PPPD for neoplasms proximal to the ampulla, and infra-ampullary PPPD for lesions distal to the ampulla. Follow-up data were available for 65% of EMR and 73% of surgical patients.
Surgically resected neoplasia was larger with more advanced neoplasia and submucosal lesions. En bloc resection was achieved in all surgical resections and in 53% of EMRs. Post-EMR, mucosal and submucosal neoplasia recurred in 32 and 0%, respectively, including five neoplasms (26%) after an initial negative esophagogastroduodenoscopy. All recurrences were treated endoscopically. Complications occurred in 14 endoscopically and eight surgically treated patients, none requiring surgical intervention.
Post-EMR patients had higher recurrence of mucosal neoplasia, whereas submucosal neoplasms, mainly carcinoid, did not recur. Polyp size and positive resection margin were not associated with neoplasia recurrence. Patients with SNADN could benefit from a multidisciplinary approach to stratify the optimal treatment based on local expertise.
KeywordsNonampullary duodenal neoplasms Endoscopic resection Surgical resection
Argon plasma coagulation
American Society of Anesthesiologists
Endoscopic mucosal resection
Endoscopic submucosal dissection
Pancreas-preserving partial duodenectomy
Pancreas-preserving total duodenectomy
Sporadic nonampullary duodenal neoplasms
MJB and RP contributed to the collection, analysis, and interpretation of data; drafting and critical revision of the article; and generation of the figures. BB, WCC, DK, and CRSL contributed to the collection of data and critical revision of the article. MAB contributed to the analysis and interpretation of data and critical revision of the article. JAS, SPB, TAW, MBW, MR, and AJH contributed to the conception and design, experiments, and critical revision of the article. All authors approved the final draft of the article.
Compliance with ethical standards
Dr. Wallace has research grants from Olympus, NinePoint, Boston Scientific, Cosmo Pharmaceuticals, and equity in iLumen. None of these disclosures were relevant for any part of this manuscript. Drs. Michael J. Bartel, Ruchir Puri, Bhaumik Brahmbhatt, Wei-Chung Chen, Daniel Kim, Roberto C. Simons Linares, John A. Stauffer, Mauricia A. Buchanan, Steven P. Bowers, Timothy A. Woodward, Massimo Raimondo, and Horacio J. Asbun have no conflicts of interest or financial ties to disclose.
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