Introduction

The most popular endoscopic therapy for SNADETs is endoscopic mucosal resection (EMR), however it is difficult due to major serious adverse events and poor curative outcomes that result in a high recurrence rate. Underwater endoscopic mucosal resection (UEMR) has recently attracted attention as a safe and effective method for superficial non-ampullary duodenal epithelial tumors (SNADETs). However, water is a fluid and it does not remain in all areas, and because it mixes easily with other substances, it sometimes becomes cloudy and reduces visibility. A new endoscopic gel product that does not mix with fluids and tends to remain in the injected area has recently been applied to EMR and is known as gel immersion EMR (GIEMR) or under-gel EMR. Unlike water, this gel product does not mix with intestinal fluids or blood, thus ensuring a good view of the gastrointestinal tract. Furthermore, it tends to stay in the injected area due to its viscoelasticity, which may shorten the treatment time.

Aims & Methods

In the present study, we compared the efficacy and safety of UEMR and GIEMR for treatment of SNADETs.
From February 2019 to January 2023, patients who underwent UEMR or GIEMR for SNADETs at the municipal hospitals were included in the study, and treatment outcomes were compared retrospectively in both groups. We identified 31 lesions of SNADETs with 3–18 mm in diameter who underwent UEMR or GIEMR. One lesion was excluded from the analysis because it was found to be in the stomach after surgery. The primary endpoint in this study was the difference in procedure time between the GIEMR and UEMR groups. The procedure time was defined as the time from the start of normal saline or gel injection into the lumen until the polyp was completely removed. En bloc resection rate, R0 resection rate and adverse events were evaluated as secondary endpoints.

Results

The 30 lesions in 29 patients were divided into the UEMR (n=12) and GIEMR (n=18) groups. There were no differences in age, gender, location, morphology and histological type between the UEMR and GIEMR groups, although the GIEMR group had a significantly larger median tumor diameter size (7 mm vs 11 mm, P=0.0006). GIEMR significantly reduced the procedure time compared with UEMR (5.5 min vs 10 min, P=0.016). There was no significant difference between the UEMR and GIEMR groups for en bloc resection rate (91% vs 94%, P=1.0) and R0 resection rate (58% vs 78%, P=0.42). No serious complications were observed in either group.

Conclusion

GIEMR was safe and had good therapeutic results for SNADETs and showed the potential to accelerate the procedure time compared with UEMR. This method may be particularly useful in areas where immersion in water is difficult. A multicenter study is needed to confirm the validity of our results.

Introduction

The ulcers after duodenal endoscopic resection (ER) are exposed to bile and pancreatic juice, therefore delayed perforation and bleeding are major complications. The condition caused by perforation can become serious, requiring surgical treatment and even death.
As a preventive measure, the suture of the ulcer after ER has been reported to be effective. There are two main suture methods: endo clips and laparoscopic suturing.

Aims & Methods

The aim of this retrospective study is to investigate the outcome of Endoscopic submucosal dissection (ESD) and laparoscopic and endoscopic co-operative surgery (D-LECS) for superficial non-ampullary duodenal epithelial tumors (SNADETs). ESD ulcer was sutured with endo clips in ESD group, and with laparoscopic suture in D-LECS group.
One hundred seventy-eight patients with SNADETs who underwent ESD and 41 patients with SNADETs who underwent D-LECS from November 2002 to February 2025 were investigated outcome of procedure. The patient’s characteristics in ESD and D-LECS were as follows. male/female: 124/54 and 27/14, median age: 62 (37-86) and 67 (37-83) years old, location of the tumor (bulbs/2^nd/3rd portion): 15/139/24 and 0/32/9, major macroscopic type (0-I/0-IIa/0-IIb/0-IIc): 5/91/1/81 and 1/32/0/8. Only major macroscopic type was difference significantly between ESD and D-LECS (p=0.001). SM1 was defined as submucosal invasion of less than 500 μm, and SM2 was defined as deeper. R0 was defined as lateral and vertical margin negative, and lymph-vascular involvement negative. DLECS was selected when it was predicted that endo clips suture might be insufficient, or when the scope maneuverability was poor.

Results

1. Median procedure time was 36 (7-245) in ESD and 351 (202-673) minutes in D-LECS, respectively(p<0.001). Median diameter of resected specimen was 17 (8-66) and 38 (17-70) mm(p<0.001). Median diameter of resected specimen and tumor was 10 (2-63) and 27 (14-52) mm(p<0.001). Intramucosal tumor (Vienna classification category 3 to 5.1) /T1bSM (category 5.2): 176/2 and 37/4 (p=0.01).
2. The en bloc resection was 90% (161/178) and 95% (39/41), respectively (p=0.53). R0 resection rate was 85% (151/178) and 88% (36/41) (p=0.62).
3. The rate of complete suture for ESD ulcer was 92% (164/178) in ESD group and 100% in D-LECS group, respectively (p=0.07). The details in D-LECS are as follows: 27% (11/41) of laparoscopic suture alone and 73% (30/41) of laparoscopic and endo clips suture.　
4. Complications: intraoperative perforation was 2% (4/178) and 10% (4/41) (p=0.04). Intraoperative bleeding requiring blood transfusion was 0% and 0%. Delayed perforation was 1% (2/178) and 0% (p=1.00). Delayed bleeding was 2% (4/178) and 0% (p=1.00).
Discussion:
1. The DLECS group treated larger cases and had more intraoperative perforations, but no delayed perforation or bleeding was observed.
2. Laparoscopic suture of the pancreatic side was not possible, but complete suture was achieved in all cases by adding a clip from the luminal side endoscopically.
3. Even after complete suture by ESD, delayed perforation can still occur. Therefore, if abdominal pain occurs, a CT scan should be performed immediately.　And if perforation is suspected, laparoscopic re-suture should be considered immediately.

Conclusion

DLECS for large SNADETs has similar outcome of ESD, and is an effective treatment. DLECS should be considered when complete suture with a clip is predicted to be difficult or when the scope maneuverability was poor.

References

None

Introduction

The ulcers after duodenal endoscopic resection (ER) are exposed to bile and pancreatic juice, therefore delayed perforation and bleeding are common. As a preventive measure, the suture of the ulcer after ER has been reported to be effective. Our data are shown as follows. From January 2007 to January 2018, ER was performed for 219 duodenal tumors. We compared 211 lesions in the suture group with 8 lesions in the non-suture group. Delayed perforation was 0% in the suture group and 13% (1/8) in the non-suture group, showing a significant difference (p=0.0365). Delayed bleeding was 1% (3/211) in the suture group and 25% (2/8) in the non-suture group, showing a significant difference (p=0.01). Therefore, the suture of the ulcer after ER is essential. If the ulcer is small after ER, it can be sutured endoscopically, but if it exceeds 3 cm, it is difficult to suture with the endoscope alone.

Aims & Methods

The aim of this study is to investigate the outcome of duodenal laparoscopic and endoscopic co-operative surgery (D-LECS) for superficial non-ampullary duodenal epithelial tumors (SNADETs).
First, tissue around duodenum is dissected laparoscopically. Second, endoscopic submucosal dissection (ESD) is performed using saline injection, Hook knife, and VIO 300D or VIO3. Sites with poor maneuverability endoscopically were resected with laparoscopic assistance. Third, ulcer after ER is sutured laparoscopically. If inadequate, endo clip is added.
Thirty-five patients with SNADETs who underwent D-LECS from January 2014 to March 2023 were investigated outcome of procedure. The patient’s characteristics were as follows. male/female: 23/12, median age 65 (37-83) years old, location of the tumor (bulbs/2^nd/3rd portion): 3/27/5, major macroscopic type (0-I/0-IIa/0-IIc): 1/29/5. pancreatic side/ non-pancreatic side of duodenum: 26/9.
SM1 was defined as submucosal invasion of less than 500 μm, and SM2 was defined as deeper. R0 was defined as lateral and vertical margin negative, and lymph-vascular involvement negative. Median follow-up period was 13 (0-42) months.

Results

1. Median procedure time was 351 (195-673) minutes. In it, median endoscopic procedure time and laparoscopic procedure time were 205(132-429) and 131(67-420) minutes, respectively. Median diameter of resected specimen and tumor were 40 (26-70) and 27 (14-53) mm, respectively. Intramucosal tumor (Vienna classification category 3 to 5.1) /T1bSM2 (category 5.2): 31/4. The median length of hospital stay was 9 (8-15) days.
2. The en bloc resection and R0 resection rate were 94% (33/35), 83% (29/35), respectively.
3. Complications: intraoperative perforation was 8% (3/35). The intraoperative perforation site was sutured laparoscopically after ESD was completed. Intraoperative bleeding requiring blood transfusion, delayed perforation, and delayed bleeding were 0%.
4. The rate of complete closure by laparoscopy was 0% (0/26) for pancreatic side, and all of them were sutured with endo-clips and polyglycolic acid sheets. And that for non-pancreatic side was 100% (9/9).
5. Prognosis
Two cases of T1bSM2 were underwent pancreaticoduodenectomy, and there were no residual tumor and no lymph node metastasis. There has been no recurrence during twenty-eight and forty-two months after DLECS,
T1aM and T1bSM1 were followed up, and no local or metastatic recurrence was observed.

Conclusion

DLECS enabled complete closure of ulcers after ER regardless of size or location. Therefore, it is a safe and effective treatment for large SNADETs.

Introduction

Cold snare polypectomy (CSP) and underwater endoscopic mucosal resection (UEMR) represent relatively novel techniques for the management of superficial non-ampullary duodenal epithelial tumors. While CSP has been demonstrated to be safe and efficacious in a large-scale clinical trial for non-ampullary duodenal adenomas (NADAs) with a diameter of less than 10 mm [1], UEMR has been shown to be safe and effective in a prospective clinical trial for NADAs with a diameter of less than 20 mm [2]. However, there is no consensus on which technique should be used for NADAs 10 mm or less.

Aims & Methods

This study aimed to evaluate the treatment outcomes of CSP and UEMR for NADAs 10 mm or less. Patients who underwent CSP or UEMR for NADAs 10 mm or less at our institution between January 2015 and December 2022 were included, excluding FAP and local recurrence cases. Adenomas were defined as either Vienna classification category 3 on preoperative biopsy or endoscopically diagnosed as adenomas. The decision to perform either CSP or UEMR, as well as mucosal closure at the ulcer base after resection, was left to the discretion of the endoscopist. Procedure time was measured from snare visibility on the monitor until the end of resection for CSP, and from the beginning of water immersion until the end of resection for UEMR. The resected specimens were pinned to the corkboard and submitted to the pathology department. Follow-up endoscopy was conducted 2–3 months after endoscopic treatment to confirm the presence or absence of residual lesions, followed by an annual endoscopic examination.

Results

A total of 51 lesions were treated using CSP, while 29 lesions were treated with UEMR. The location of the lesions was distributed as follows: 9.8%, 84.3%, and 5.9% for the first, second, and third regions in the CSP group; and 13.8%, 82.5%, and 6.3% in the UEMR group (p=0.84). The difference in lesion diameter between the CSP and UEMR groups was not statistically significant (6.3±2.5 mm and 7.3±2.2 mm, respectively; p=0.06). Preoperative biopsy was performed in 43.1% of the CSP group and 58.6% of the UEMR group (p=0.18). The mean procedure time for CSP and UEMR was 4.6±4.2 min and 6.1±6.9 min, respectively (p=0.29). Mucosal closure at the ulcer base was performed in 56.9% of the CSP group and 100% of the UEMR group (p<0.01). Neither group experienced intraoperative perforation, postoperative bleeding, or delayed perforation (95% CI: 0–7.0% for the CSP group, 0–11.9% for the UEMR group). The en-bloc resection rates were 96.8% for CSP and 100% for UEMR (p=0.17), and the electric current application rate for CSP was 7.8%. The final pathological diagnosis in the CSP group was 82.4% adenoma, 3.9% intramucosal adenocarcinoma, and 13.7% non-neoplasm, while in the UEMR group, it was 89.7% adenoma, 10.3% intramucosal adenocarcinoma, and 0% non-neoplasm (p=0.02). The lateral and vertical margin-negative rates were 62.8% and 94.1% in the CSP group, and 62.1% and 100% in the UEMR group, respectively (p=0.95 for lateral margin, p=0.19 for vertical margin). Local recurrence was detected in 3.9% of the CSP group and 0% of the UEMR group.

Conclusion

The rates of negative margins for both lateral and vertical margins were comparable between CSP and UEMR. Despite this, two recurrence cases were observed in the CSP group. UEMR was as safe as CSP, with no intraoperative or postoperative adverse events reported. Furthermore, given that the preoperative diagnosis of adenoma may include a certain number of adenocarcinomas, UEMR may be considered the preferred method for endoscopic resection of NADAs ≤10 mm in size.

References

[1] K. Takizawa, Y. Takeuchi, M. Ohmori, J. Fujisaki, S. Yoshimizu, T. Iwai, T. Yamada, T. Suzuki, M. Takeuchi, M. Yoshida, A. Miyakawa, H. Furuhashi, M. Matsuda, H. Araki, K. Ohno, T. Shimura, T. Ohta, K. Mori, H. Ishikawa, T. Gotoda, D-COP study Group. COLD SNARE POLYPECTOMY FOR SUPERFICIAL NON-AMPULLARY DUODENAL EPITHELIAL TUMOR: A MULTICENTER PROSPECTIVE CONFIRMATORY TRIAL (D-COP TRIAL). ueg journal. 2021 Oct suppl. 27-28.
[2] Yamasaki Y, Uedo N, Akamatsu T, Kagawa T, Higashi R, Dohi O, Furukawa M, Takahashi Y, Inoue T, Tanaka S, Takenaka R, Iguchi M, Kawamura T, Tsuzuki T, Yamasaki T, Yamashina T, Nasu J, Mannami T, Yamauchi A, Matsueda K, Aizawa S, Mitsuhashi T, Okada H; D-UEMR Study Group. Nonrecurrence Rate of Underwater EMR for ≤20-mm Nonampullary Duodenal Adenomas: A Multicenter Prospective Study (D-UEMR Study). Clin Gastroenterol Hepatol. 2022 May;20(5):1010-1018.e3.

Introduction

Underwater endoscopic mucosal resection (U-EMR) is an emerging technique in the management of superficial nonampullary duodenal epithelial tumours (SNADETs). Nevertheless, particularly in Western centers, its application has not been comprehensively assessed.

Aims & Methods

Our aim was to compare the efficacy and safety of U-EMR versus conventional EMR (C-EMR) for the endoscopic treatment of SNADETs.
Retrospective case-control study that analyzed all patients who underwent duodenal EMR in a tertiary reference center, between 2015 and 2022. SNADETs ≥10 mm removed by U-EMR or C-EMR were included. Primary endpoint was residual/recurrent adenoma rate (RAR). Secondary outcomes were rates of technical success, en bloc resection, and adverse events (AE).

Results

A total of 40 duodenal adenomas (31 patients) were included (U-EMR n=18; C-EMR n=22). Median lesion size was 16.5 ± 13.3 mm. Lesions were predominantly IIa (47.5%) and IIa+c (20%) - Paris classification. Most lesions were in the second portion of duodenum (n=35).
Groups were similar regarding age, gender and lesion size. There were no significantly statistically differences between groups regarding technical success (100% U-EMR vs. 90.9% C-EMR, p=0.19) and en bloc resection rate (44.4% U-EMR vs. 54.2% C-EMR, p=0.53). RAR was higher in the C-EMR group (n=6/20, 30% vs. n=1/10, 10%, p=0.22), although without statistically significance. Post-EMR defects were more commonly closed in U-EMR group (83.3% vs. 45.5%, p <0.05). Peri-procedural AE rate (bleeding n=2 [11.1%] U-EMR vs. bleeding n=3 [13.6%] C-EMR, p=0.81) was similar between groups. There were no delayed complications in the U-EMR group while in the C-EMR group there were 2 cases of bleeding (0% vs. 9.1%, p= 0.19).

Conclusion

In our study, compared to C-EMR, U-EMR showed similar RAR and safety, highlighting its role as a feasible therapeutic option for the management of SNADETs.