Introduction

Endoscopic resection (ER) of large (>/-15mm) duodenal laterally spreading lesions (D-LSLs) is now standard of care. Data on prevalence, risk factors and outcomes of post-duodenal ER strictures are absent; we sought to evaluate this is in a Western cohort.

Aims & Methods

We report a retrospective analysis of a prospectively collected cohort of D-LSLs following ER in an expert tissue resection centre. Strictures were considered "severe" if patients experienced obstructive symptoms, "moderate" if an adult gastroscope could not pass the stenosis, or "mild" if there was resistance on successful passage. If dilatation was performed, 2-4 weekly dilatation sessions were conducted until scope passage without resistance was achieved as well as symptom resolution where applicable. Primary outcomes included stricture prevalence, risk factors and management.

Results

Over 193 months until February 2023, 246 lesions in 239 patients were included (51.2% male, median age 70 years [IQR 14], median size 35mm [IQR 25]). 30 (12.2%) resections resulted in stenosis; 14 mild (46.7%), 4 moderate (13.3%) and 12 severe (40%). 18 (7.3%) required balloon dilation (median number of sessions, 2 [IQR 6]). Stricture resolution following index-ER was achieved with balloon dilatation alone in 15/18 patients (83.3%). Two patients had an excellent response to lumen apposing metal stent insertion following ER of fully circumferential D-LSL. A patient with an incompletely resected fully circumferential D-LSL, in which adenocarcinoma was confirmed post-ER, required palliative stent placement after 3 sessions of balloon dilatation, due to gastric outlet obstruction caused by residual tumour. Post ER-defect circumference ≥80% proved the strongest independent predictor for stricture formation (OR 62.9 (CI 17.9-276.7, p<0.001; Table 1). The incidence of stricture formation with an ER-defect ≥80%, 60-79% and <60% was 72.2% (n=26/36), 12.5% (n=4/32) and 0% (n=0/178) respectively. All severe strictures (12/12, 100%) occurred in ER-defects ≥80%.

Table 1: Logistic regression to determine lesion characteristics, endoscopic resection (ER) technique and post-ER outcomes which are risk factors for stricture development

Conclusion

ER-defect circumference strongly predicts stricture formation following ER of D-LSL. These findings can be used to guide patient counselling and post-procedural care. Based on our findings, we recommend a management algorithm determined by the extent of the ER-defect. When the ER-defect extends ≥80% of the luminal circumference, endoscopic assessment for stricture formation should be scheduled routinely at 3 weeks. When the ER-defect involves 60-79%, clinical consultation at 2-3 weeks should be conducted to screen for obstructive symptoms, and gastroscopy organised if the patient is symptomatic. ER-defects <60% can safely return to routine surveillance.

Introduction

Gastric adenoma is recognized as a premalignant lesion.¹Much of the literature lumps all adenomas together with different classifications. These are few western reports regarding the prevalence, associated risk factors and outcomes of endoscopic management of different subtypes of gastric adenoma.

Aims & Methods

Aims: The aim of this study is to determine the prevalence, potential predictors, and outcomes of endoscopic management of the different subtypes of gastric adenoma.
Methods: Of 162 consecutive patients who underwent endoscopic resection for gastric lesions between 2017 and 2022 at our center, 79 patients were enrolled. All the hyperplastic polyps (n=37) and subepithelial lesions (n=46) were excluded. The patient clinical characteristics, endoscopic and histopathological features of gastric lesions were retrospectively collected. Patients were divided according to the histological types of gastric adenoma into 4 groups: intestinal group (n= 49), foveolar group (n= 23),pyloric group (n= 6) and oxyntic group (n=1). We statistically compared the clinical and endoscopic features of the three groups. In addition to the analysis of the outcomes of endoscopic resection of gastric adenomas.

Results

Of the 79 patients with a mean follow-up of 2622 months, 51 patients were males (65 %) and 28 patients were females (35%). Forty-nine patients (49/79,62%) had intestinal adenoma, 23 patients (29%) showed foveolar adenoma, 6 patients (8%) developed pyloric adenoma and only 1 patient (1%) had oxyntic adenoma. The mean age was significantly older in the intestinal group (71 ± 13 years vs. 64 ± 16 years vs. 58 ± 18 years, p = 0.03). Intestinal adenomas were significantly associated with family history of gastric adenocarcinoma (14% vs. 4% vs. 0%, p = 0.01) and history of statin intake (39% vs. 26% vs. 0%, p = 0.04).Foveolar adenomas were significantly associated with multiple lesions (≥3 lesions) (p < 0.001) and 0-IIa+IIc Paris classification (6/23, 26%). the size of largest polyp was significantly higher among pyloric group (28 ±15, p= 0.00). Among intestinal group, 33/49 patients (67%) had atrophic gastritis. 82% of the adenomas were resected by ESD with histologically complete resection (R0) in 72/79 patients (91%). Although the difference was not statistically significant (p = 0.4), adenocarcinoma was most frequently encountered among the intestinal adenoma group (17/49, 35%). The post endoscopic resection outcome was comparable among 3 groups with overall recurrence rate (group1:8% vs. group 2:17% vs group 3:17%, P = 0.07) with a comparable mean time to recurrence among three groups (21 ± 17 months vs. 20±17months vs. 14 months, p=0.8). Family history of gastric adenocarcinoma (HR=1.33, p< 0.001) and active helicobacter pylori infection (HR=1.14, p < 0.001) were identified as independent predictors of recurrence after endoscopic resection of different gastric adenoma. Among baseline endoscopic characteristics, polyp size ³ 30mm(HR= 2.04, p< 0.001), more than 3 polyps (HR=1.51, p<0.001), lesser curvature as lesion location (HR=1.72, p< 0.001) and morphology as Paris classification IIc are potential predictors of post resection recurrence. In addition to specimen size ³ 15mm (HR=2.19, p< 0.001) and T1b as lesion histology (HR=2.07, p< 0.001), in the histopathological examination.

Conclusion

The present study clarifies the endoscopic and histopathological characteristics of different gastric adenomas, in addition to the potential predictive factors for each subtype. Potential predictors of recurrence after endoscopic resection emphazie the importance of endoscopic follow up.

References

1. Fujiwara, Y. et al. Diagnosis of borderline adenomas of the stomach by endoscopic mucosal resection. Endoscopy 28, 425–430 (1996).

Introduction

Endoscopic resection (ER) of duodenal tumors carries a high risk of intraoperative or delayed perforation because of the thin duodenal wall and exposure to bile and pancreatic juice. Delayed perforation can particularly cause serious condition due to the leakage of the digestive fluids. The detailed management and clinical course following duodenal perforation remains unclear. This study aimed to clarify the optimal management of duodenal perforation following ER.

Aims & Methods

This single-center retrospective study included cases of perforation among patients who underwent ER for duodenal tumors at our institution between April 2013 and October 2024. The study endpoint was the clinical course after perforation, including the hospitalization period after ER for duodenal tumors. Perforation was defined as the presence of extraluminal gas on computed tomography (CT) scan. Delayed perforation was defined as a perforation that was not endoscopically recognized during the procedure but was diagnosed postoperatively. In contrast, intraoperative perforation was defined as a case in which a perforation was endoscopically identified during the endoscopic procedure. Long hospitalization was defined as a hospital stay of 20 days or longer.

Results

Of the 1,475 cases with duodenal tumors underwent ER during the study period, intraoperative perforation occurred in 8 cases (0.5%) and delayed perforation in 10 cases (0.7%). The median age of patients with perforation was 62 (range: 47–80) years, and 50% (9 patients) were male. The 18 cases included 6 cases of endoscopic papillectomy (EP), 7 cases of endoscopic mucosal resection (EMR), 2 cases of endoscopic submucosal dissection, and 3 cases of endoscopic submucosal resection with a ligation device. Among the cases of intraoperative perforations, long hospitalization, 61 days of conservative treatment, was required in one case who developed a large perforation during scope insertion of single‑balloon enteroscopy for duodenal adenoma resection. The remaining 7 cases achieved successful endoscopic closure intraoperatively and hospitalization periods were within 17 days. Of the 10 delayed perforation cases, 2 occurred after EP and 8 after EMR for non-ampullary tumors. The median time from the end of endoscopic resection to the diagnosis of perforation was 24 hours (4–46 hours). The median hospitalization period of the cases with delayed perforations was 32 days (9–81 days), and significantly longer than that of intraoperative perforation (13 days) (p<0.05). Long hospitalization was required in 8 cases (80%) of delayed perforation. None of the delayed perforation cases required surgical intervention, and endoscopic nasobiliary and nasopancreatic duct drainage (ENBPD) was performed in 7 cases (70%). Ascites was observed on CT scan at the time of diagnosis of delayed perforation in 7 of the 8 patients who required long hospitalization. One case without ascites at the diagnosis of delayed perforation still required long hospitalization, possibly due to the 10-hour delay from the diagnosis to ENBPD. On the other hand, two cases who did not need long hospitalization showed no ascites at the diagnosis of delayed perforation.

Conclusion

Compared to intraoperative perforation, delayed perforation was associated with significantly prolonged hospitalization, particularly in cases with ascites. Early detection of ascites and prompt initiation of ENBPD may help mitigate the clinical burden. Establishing an emergent backup system for ENBPD is essential for the safe management of delayed perforation after duodenal ER.

Introduction

Complete excision of upper gastrointestinal sub-epithelial lesions (SELs) eliminates diagnostic uncertainty, obviates the need for surveillance and may be necessary for definitive diagnosis and management. Current guidelines lack precision and cohesion, and surgery is associated with significant morbidity. Herein, we describe and report on the outcomes of our SEL algorithm for endoscopic (SAFE) resection.

Aims & Methods

SELs were enrolled prospectively over 115 months until March 2023. All underwent axial (CT) imaging and endoscopic-ultrasonography (EUS) to exclude a large exophytic component or invasion into local structures, and assess for muscularis propria involvement.

Results

106 SELs were resected (mean age 60.6±13.4, 51.9% male; 41 oesophageal, 65 gastric). Oesophageal SELs underwent ESD (n=22) or STER if MP involvement was suspected (n=19). Gastric SELs underwent STER (n=6 at cardia), ESD (n=47) or exposing-EFTR (n=12). Technical success was 97.6% and 92.3% respectively. Five (7.7%) were completed laparoscopically due to deep and broad full-thickness involvement. Five (7.7%) required laparoscopic gastrotomy and surgical retrieval after successful resection and closure due to a large lesion size (mean 47 mm). There was no delayed bleeding, perforation or recurrence at a median of 13 months.

Conclusion

Upper GI SELs are effectively and safely treated by endoscopic resection. The SAFE approach provides a framework that facilitates structured decision-making. Oesophageal SELs suspected to involve the MP should undergo STER. Gastric SELs can be best managed by ESD with a view to proceed to exposing-EFTR. A laparoscopic UGI surgeon should be available in case surgical retrieval of the specimen or laparoscopic completion is required.

Disclosure

Michael J. Bourke: Research Support: Olympus, Cook Medical, Boston Scientific.

Introduction

Sporadic duodenal adenomas are uncommon in comparison to other gastro-intestinal adenomas and often an incidental finding in upper gastrointestinal endoscopy. Recent studies indicate an increasing incidence of these lesions.¹

Aims & Methods

A retrospective review of upper endoscopies performed over the past 10 years was conducted to identify cases of duodenal adenomas. Patients with polyposis syndromes and ampullary adenomas were excluded, resulting in a sample of 41 patients with sporadic duodenal adenomas. In addition, a control group of 41 randomly selected individuals from the same 10-year span, matched by age and gender, was used for comparison. Potential risk factors for duodenal adenomas were collected.

Results

The prevalence of duodenal adenomas was 0.22%. The mean age of affected individuals was 69 years, out of which 24 were males. Most of the adenomas were endoscopically removed (68.3%), three patients had recurrent adenomas and one progressed into adenocarcinoma. A significant association was observed between smoking and the presence of duodenal adenomas (p = 0.037). Family history of gastrointestinal neoplasia was related to the occurrence of duodenal adenomas (p = 0.043). In addition, in comparison to the control group, the duodenal adenoma group had a significantly higher number of affected family members with gastrointestinal neoplasia (p = 0.001). Furthermore, the duodenal adenoma group had a significantly higher number of colorectal adenomas compared to the control group (p < 0.001). No statistically significant associations or differences to the control group were found amongst other variables.

Conclusion

Although sporadic duodenal adenomas are rare, their potential for recurrence and progression to adenocarcinoma warrants careful surveillance. Smoking and family history of gastrointestinal neoplasia appear to be potential risk factors for sporadic duodenal adenomas. Additionally, the higher prevalence of colorectal adenomas in these patients highlights the importance of colorectal cancer screening in this population.

References

(1) Culver, E., & McIntyre, A. (2011). Sporadic duodenal polyps: classification, investigation, and management. Endoscopy, 43(02), 144–155. https://doi.org/10.1055/s-0030-1255925

Introduction

Endoscopic submucosal dissection (ESD) has evolved to become a viable treatment option for oesophageal squamous dysplasia (SD) and early squamous cell carcinoma (ESCC). Although enbloc, R0, excision has the potential to yield an endoscopic cure, surgery remains the standard of care in the West. Furthermore, Western data pertaining to endoscopic outcomes is limited. We aimed to assess the efficacy and safety of ESD for SD and ESCC in a single tertiary referral centre.

Aims & Methods

We conducted a prospective observational cohort study over 87 months until November 2023 in consecutive patients undergoing ESD for SD or ESCC. The primary outcomes were enbloc, R0 and curative resection rates. Secondary outcomes included procedure duration, tumor recurrence and adverse events.

Results

112 consecutive patients were referred for treatment and underwent ESD (median age 73 [IQR 68-78]; 50% male; Table 1). Median lesion size was 30 mm (IQR 20-50mm) and Paris IIa was the most common morphology (58.9%). Enbloc resection was achieved in 109 (97.3%) and R0 excision in 87 (77.7%). Curative resection in cases of LGD and HGD, where margins were clear of dysplasia, was 7/11 (63.6%) and 31/34 (91.2%) respectively. In those with T1a/T1b SCC, the curative resection rate was 20/61 (32.8%). In T1a SCC lesions, 11/20 (55.0%) had a curative ESD. Of the remainder, 6/9 were poorly differentiated, 1/9 had LVI, and 2/9 had positive margins (1 deep, 1 peripheral). In T1b SCC lesions, 9/41 were curative (22.0%). The remainder were either poorly differentiated, >T1b-SM1, LVI positive or a combination. In those with T1a/T1b disease, without adverse tumor biology, ESD achieved curative resection in 20/22 (90.9%).
In the 41/61 (67.2%) T1a/T1b patients that did not meet criteria for cure, subsequent treatment included surgery (n=5), radiotherapy (n=5) and chemoradiotherapy (n=1). After MDT discussion, the remaining 30 were managed conservatively, due to advanced age or comorbidities. In these, recurrence occurred in 6/30 patients (1 local, 3 nodal, 2 metastatic) at a median follow up of 12 months (6-18 months). The median hospital length of stay was 1 day (IQR 1-3). Oesophageal strictures occurred in 46 patients (41.1%), requiring a median of 3 dilations (IQR 1-8). There were 2 cases of delayed bleeding. There were no perforations.

Table 1

Conclusion

ESD is curative for low and high-grade dysplasia. In a Western setting, ESD offers definitive T-staging and has the potential to yield a cure in almost 33% of T1a and T1b SCC cases. Due to a high risk of disease recurrence, adjuvant therapy should be considered in cases of a non-curative resection.