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Endoscopic resection and suturing methods for non-ampullary duodenal submucosal tumors: “mini-invasive” treatments that should never be underestimated

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Abstracts

Objective

To evaluate the effectiveness and safety of endoscopic resection and various suturing methods to treat non-ampullary duodenal submucosal tumors (NAD-SMTs).

Design

We performed a retrospective observational study of patients with NAD-SMTs who underwent endoscopic resection at Zhongshan Hospital, Fudan University, China, between June 2017 and December 2020. Data on patient characteristics, treatments and follow-up results were collected. The association between clinicopathologic characteristics and different suturing methods or adverse events were analyzed.

Results

Of 128 patients analyzed, 26 underwent endoscopic mucosal resection (EMR), 64 underwent endoscopic submucosal excavation (ESE), and 38 underwent endoscopic full-thickness resection (EFTR). EMR and ESR are both appropriate for non-full-thickness lesions, whereas ESE is more appropriate for tumors located in the bulb or descending duodenum. Gastric tube drainage is more strongly recommended after ESE. Satisfactory suturing is also vital endoscopic resection of NAD-SMTs. Metallic clips are often used in EMR or ESE of non-full-thickness lesions. The pathological findings revealed that the full-thickness lesions were predominantly gastrointestinal stromal tumors (GIST), Brunner’s tumor or lipoma, and the surgeons usually used purse-string sutures to close the wounds. The operation time was longer for purse-string suture closure than metallic clip closure. Eleven patients had complications. Risk factors for adverse events included large-diameter tumor (≥ 2 cm), location in the descending part of the duodenum, involvement of the fourth layer of the duodenal wall, EFTR, and GIST.

Conclusions

Endoscopic resection of NAD-SMTs is effective but is associated with a high incidence of complications due to their anatomical peculiarities. Preoperative diagnosis is quite important. Careful selection of treatment and suturing methods are necessary to reduce the risk of adverse effects. Given the increased frequency of severe complications during or following duodenal endoscopic resection, this procedure should be performed by experienced endoscopists.

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Abbreviations

NAD-SMTs:

Non-ampullary duodenal submucosal tumors

EMR:

Endoscopic mucosal resection

EPMR:

Endoscopic piecemeal mucosal resection

ESE:

Endoscopic submucosal excavation

EFTR:

Endoscopic full-thickness resection

GIST:

Gastrointestinal stromal tumor

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Funding

This study was supported by the grant from the National Natural Science Foundation of China (81902394) & Shanghai Dawnlight program (20CG07) & Excellent Young Scholar Foundation of Zhongshan Hospital (2021ZSYQ08).

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Author notes

  1. Ping-ting Gao, Sheng-li Lin and Pei-yao Fu have contributed equally to this work.

Authors and Affiliations

  1. Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, 180 FengLin Road, Shanghai, 200032, China

    Ping-ting Gao, Sheng-li Lin, Pei-yao Fu, Quan-lin Li, Ming-yan Cai, Li-li Ma, Yi-qun Zhang, Yun-shi Zhong, Li-qing Yao, Wei-feng Chen & Ping-hong Zhou

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  1. Ping-ting Gao
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Contributions

PG, SL and PF collected the data and wrote the manuscript. QL, LM, YZ, YZ and LY contributed to clinical review and discussion. WC and PZ designed the study, provided the case, and made critical revisions. All authors approved the final version of the manuscript.

Corresponding authors

Correspondence to Wei-feng Chen or Ping-hong Zhou.

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Disclosures

Drs. Ping-ting Gao, Sheng-li Lin, Pei-yao Fu, Quan-lin Li, Min-yan Cai, Li–li Ma, Yi-qun Zhang, Yun-shi Zhong, Li-qing Yao, Wei-feng Chen, Ping-hong Zhou have no conflicts of interest or financial ties to disclose.

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Supplementary Information

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464_2023_10013_MOESM1_ESM.tiff

Supplementary file1 (TIFF 62501 KB) (A & B) Endoscopic mucosal resection of a heterotopic pancreas. (C & D) A giant lipoma in the descending duodenum was resected using an IT knife and the wound was closed using metallic clips. (E & F) A 2 cm lipoma in the duodenal bulb was resected by endoscopic submucosal excavation using a hybrid-knife. The wound was closed using metallic clips. (G & H) Endoscopic full-thickness resection (EFTR) of a 0.8 cm gastrointestinal stromal tumor (GIST) located in the duodenal bulb using a hook knife. The wound was closed using metallic clips. (I & J) EFTR of a 2 cm GIST in the duodenum junction. The wound was closed using purse-string sutures

Supplementary file2 (DOCX 30 KB)

Supplementary file3 (DOCX 29 KB)

Supplementary file4 (DOCX 30 KB)

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Gao, Pt., Lin, Sl., Fu, Py. et al. Endoscopic resection and suturing methods for non-ampullary duodenal submucosal tumors: “mini-invasive” treatments that should never be underestimated. Surg Endosc 37, 6135–6144 (2023). https://doi.org/10.1007/s00464-023-10013-0

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  • DOI: https://doi.org/10.1007/s00464-023-10013-0

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