Endoscopic resection of sporadic duodenal adenomas: comparison of endoscopic mucosal resection (EMR) with hybrid endoscopic submucosal dissection (ESD) techniques and the risks of late delayed bleeding.
BACKGROUND
Endoscopic resection (ER) of sporadic duodenal adenomas (SDAs) is an alternative treatment strategy to surgical excision but carries substantial risks of bleeding. Endoscopic submucosal dissection (ESD) of SDAs has a high rate of perforation. This study aimed to examine the outcome for ER of SDAs in two large UK centers, both using a novel hybrid endoscopic mucosal resection (EMR) with ESD.


METHODS
Prospective endoscopy databases of ER cases were examined for the period January 2005 to December 2012. Records were analyzed for patient demographics, lesion size and morphology, staging investigations, procedural technique, outcomes, histology, complications, and follow-up assessments.


RESULTS
The study included 34 patients. The mean adenoma size was 25 mm. Of the 34 cases, 21 (62 %) were managed by the traditional snare EMR technique, 12 (35 %) by the hybrid EMR-ESD technique, and 1 by full en bloc ESD. Successful resection was achieved in 33 (97 %) of the 34 cases. En bloc resection and recurrence rates did not differ significantly between the cases treated by EMR and those treated by hybrid EMR-ESD. Three episodes of significant delayed bleeding occurred 1-18 days after the procedure. No perforations or deaths occurred. The risk of delayed bleeding was higher for the lesions 30 mm in diameter or larger than for the lesions smaller than 30 mm (33% vs. 0 %; p = 0.003). The risk of delayed bleeding was not related to the ER technique used (EMR, 9.5 %; ESD/hybrid, 7.7 %; p = 0.855).


CONCLUSIONS
Endoscopic resection is an effective treatment for SDAs and can avoid the need for open surgery. This is the first series to report the use of a hybrid EMR-ESD technique for the treatment of SDAs in a Western setting. However, this technique did not confer any major outcome benefits over EMR. The risk of delayed bleeding is substantial, and bleeding may occur up to 18 days after the procedure. The risk of delayed bleeding was increased with lesions larger than 30 mm but was not influenced by the endoscopic technique.
Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK, petebasford@hotmail.com.
Peter John
PJ
Basford
Regi
R
George
Emma
E
Nixon
Tehreem
T
Chaudhuri
Rob
R
Mead
Pradeep
P
Bhandari
D000236:Adenoma / Q000473:pathology / Q000601:surgery*; D000368:Aged; D000369:Aged, 80 and over; D004210:Dissection / Q000379:methods*; D004379:Duodenal Neoplasms / Q000473:pathology / Q000601:surgery*; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology*; D006801:Humans; D015994:Incidence; D007413:Intestinal Mucosa / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D019106:Postoperative Hemorrhage / Q000453:epidemiology*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D006113:United Kingdom / Q000453:epidemiology