title: Endoscopic resection of large duodenal and papillary lateral spreading lesions is clinically and economically advantageous compared with surgery.
abstract: Background and study aimsAdenomas of the duodenum and ampulla are uncommon. For lesions ≤ 20 mm in size and confined to the papillary mound, endoscopic resection is well supported by systematic study. However, for large laterally spreading lesions of the duodenum or papilla (LSL-D/P), surgery is often performed despite substantial associated morbidity and mortality. We aimed to compare actual endoscopic outcomes of such lesions and costs with those predicted for surgery using validated prediction tools.Patients and methodsPatients who underwent endoscopic resection of LSL-D/P were analyzed. Two surgeons assigned the hypothetical surgical management. The National Surgical Quality Improvement Program (NSQIP), and the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) were used to predict morbidity, mortality, and length of hospital stay. Actual endoscopic and hypothetical surgical outcomes and costs were compared.ResultsA total of 102 lesions were evaluated (mean age of patients 69 years, 52 % male, mean lesion size 40 mm). Complete endoscopic resection was achieved in 93.1 % at the index procedure. Endoscopic adverse events occurred in 18.6 %. Recurrence at first surveillance endoscopy was seen in 17.7 %. For patients with ≥ 2 surveillance endoscopies (n = 55), 90 % were clear of disease and considered cured (median follow-up 27 months). Compared with hypothetical surgical resection, endoscopic resection had less morbidity (18 % vs. 31 %;P= 0.001) and shorter hospital stay (median 1 vs. 4.75 days;P< 0.001), and was less costly than surgery (mean $ 11 093 vs. $ 19 358;P< 0.001).ConclusionIn experienced centers, even extensive LSL-D/P can be managed endoscopically with favorable morbidity and mortality profiles, and reduced costs, compared with surgery.
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia.
authors.forename: Amir
authors.initials: A
authors.lastname: Klein
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia.|University of Sydney, Sydney, Australia.
authors.forename: Golo
authors.initials: G
authors.lastname: Ahlenstiel
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia.
authors.forename: David J
authors.initials: DJ
authors.lastname: Tate
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Burgess
authors.affiliation: Department of Surgery, Westmead Hospital, Sydney Australia.
authors.forename: Arthur
authors.initials: A
authors.lastname: Richardson
authors.affiliation: Department of Surgery, Westmead Hospital, Sydney Australia.
authors.forename: Tony
authors.initials: T
authors.lastname: Pang
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia.
authors.forename: Karen
authors.initials: K
authors.lastname: Byth
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia.|University of Sydney, Sydney, Australia.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Bourke
mesh_terms: D000236:Adenoma / Q000473:pathology / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater; D003138:Common Bile Duct Neoplasms / Q000473:pathology / Q000601:surgery*; D004379:Duodenal Neoplasms / Q000473:pathology / Q000601:surgery*; D000069916:Endoscopic Mucosal Resection / Q000009:adverse effects / Q000191:economics; D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects / Q000191:economics; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology; D012086:Reoperation; D047368:Tumor Burden