Clinical Case Summary

A 65-years-old male with a history of familial adenomatous polyposis (FAP) was scheduled for duodenal endoscopic mucosal resection (EMR) of a 2 cm lateral spreading tumor (IIa in Paris classification), located in the lower segment of the duodenal bulb with a small fraction of intrapyloric extension. Due to lesion’s location, initial attempts to adequately lift or visualize the polyp in full extent using a gastroduodenoscope with or without a mounted cap were unsuccessful (Figure 1). Colonoscope use had no effect as well. Only when we mounted an endocuff (ENDOCUFF VISION™ ) on the tip of the colonoscope we did manage to get a better fixed scope position, maximization of the endoscopic view and properly lift and resect the lesion in piecemeal EMR fashion (Figure 2). This was due to the stabilization of the scope intrapylorically with the help of the endocuff arms (Figure 3). Argon plasma coagulation was performed at the rims of the polypectomy, so as to reduce recurrence rate. Pathology report noted a tubulovillous adenoma with low and focal high-grade dysplasia. Patient is re-scheduled for repeat endoscopy in 3 months. To our knowledge this is the first documented case of a duodenal EMR performed with an endocuff assisted colonoscope in the literature. This report underlines the ability of the endocuff to achieve better fixed scope position in defiant duodenal polyps [1,2].

References

[1]. GA Paspatis et al. The use of endocuff for the facilitation of endoscopic mucosal resection in defiant colonic polyps. A case series. Hippokratia 2021; 25: 134–137.
[2]. Vanbiervliet Geoffroy et al. Endoscopic management of superficial nonampullary duodenal tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53: 522–534.

Clinical Case Summary

An 81years-old man with a medical history of recently diagnosed bullous pemphigoid, without skin lessions at presentation and reporting corticoid withdrawal, presented to the emergency department with hemodynamic instability and melena, complaining for vague chest pain. Patient was admitted to the hospital and gastroscopy was performed. Obliteration of oesophageal mucosa throughout the oesophagus and deep, diffuse esophageal lacerations extending down to the muscle layer with coexisting hemorrhagic content and thrombi in the lumen, were noted (picture 1). Differential diagnosis included either traumatic oesophageal rupture or bullous pemphigoid with oesophageal involvement. Urgent computed tomography revealed dilated oesophagus, filled with content but no free air or liquid in the mediastinum (picture 2). Based on clinical history, pemphigoid oesophageal involvement was the most prominent diagnosis. Laboratory workup revealed persistent activated partial thromboplastin time (aPTT), with an otherwise normal coagulation panel. Since there was no history of heparin treatment, other disorders such as antiphosholipid syndrome were excluded. Laboratory tests confirmed the presence of a factor VIII acquired inhibitor and ultimately led to the diagnosis of acquired haemophillia A, which was triggrered by patient’s autoimmube disorder. Therefore a six-week course of oral corticoids, cyclophosphamide and eptacog alfa as bolus intravenous infusion (an activated recombinant coagulation factor VII) were administered. Repeat endoscopy a month after admission revealed complete mucosal healing of the oesophagus (picture 3). Oral diet was re-initiated and the patient was soon discharged with no further complications. Our case indicates that systemic diseases can have a severe impact on gastrointestinal tract and past medical history must always be taken under consideration no matter how severe the endoscopic findings may be [1].

References

1) Gaspar, R et al. Bullous pemphigoid: extensive esophageal involvement. Gastrointest Endosc 2017; 86: 400–402.

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.

Clinical Case Summary

Gastrointestinal neuroendocrine tumours (NETs) are low-grade malignant tumours in the GI tract. They account for 0.4% to 1.8% of GI malignancies. Duodenal NETs are relatively rare tumours and only accounts for 2% to 3% of GI NETs.
The patient, a 68 year old male, had dyspepsia and OGD showed a 10mm subepithelial lesion (SEL) (Insert image here) in the second part of the duodenum. Biopsies revealed polypoid foveolar hyperplasia. An endoscopic ultrasound (EUS) was done to evaluate the SEL which showed a 7mm x 8mm hypoechoic lesion within the submucosal layer (insert image). There was a slit within the SEL which corresponds to the previous biopsy sampling. Differentials were GIST or pancreatic rest. Further biopsies were taken from the within the slit which concluded as a well-differentiated NET, Grade 1.
PET DOTATE scan showed tracer-avid focus in the duodenum. Chromogranin A was elevated at 1056ug/L.
In view of previous sampling with a biopsy scar now, removal of the duodenal NET was carefully thought out. Endoscopic mucosal resection (EMR) has a higher risk of perforation due to the possibility of fibrosis from the biopsies. Laparoscopic endoscopic cooperative surgery was discussed with the surgeons, however, it is invasive.
Patient then underwent underwater EMR. The duodenal NET had sufficient buoyancy whilst underwater (Insert image). A 10mm snare was used, and polypectomy with Endocut Q mode done with good margins. There was no intraprocedural bleeding nor perforation. Two clips were used to close the polypectomy site prophylactically (Insert image).
Histology demonstrated tumour cells within the lamina propria and submucosa with salt and pepper like chromatin and round nuclei. They were positive for synaptophysin and chromogranin. Ki-67 index was 2%, and the margins were clear. This was conclusive of a NET Grade 1.
This case highlights the approach and differentials to duodenal lesions, and points to be considered for endoscopic resection in the duodenum.

References

Sato Y, Hashimoto S, Mizuno K, Takeuchi M, Terai S. Management of gastric and duodenal neuroendocrine tumors. World J Gastroenterol. 2016 Aug 14;22(30):6817-28
Gaspar JP, Stelow EB, Wang AY. Approach to the endoscopic resection of duodenal lesions. World J Gastroenterol. 2016 Jan 14;22(2):600-17
Wang X, Wu Y, Cao X, Zhang X, Cheng Y, Kong L. Duodenal neuroendocrine tumor: A rare case report. Medicine (Baltimore). 2021 Feb 12;100(6):e24635
Milione M, Parente P, Grillo F, Zamboni G, Mastracci L, Capella C, Fassan M, Vanoli A. Neuroendocrine neoplasms of the duodenum, ampullary region, jejunum and ileum. Pathologica. 2021 Feb;113(1):12-18

Introduction

Recent advances in endoscopic imaging have improved the diagnostic accuracy for superficial non- ampullary duodenal epithelial tumors (SNADETs). Endoscopic resection is the treatment of choice for these lesions and endoscopic mucosal resection (EMR) is the commonly used technique. Endoscopic resection with the use of a specific distal attachment (cap-assisted EMR (CEMR)) has been reported as a safe and effective method for SNADETs.¹ However, there is limited data on the technical aspects of the same. Duodenal resections have a high risk of delayed bleeding and perforation probably due to direct exposure of ulcer to biliary and pancreatic juices. Hence, appropriate closure is absolutely essential. We have previously reported safety of closure of duodenal endoscopic resections using over-the-scope and conventional clips.² We now report on the safety and efficacy of using only hemoclips for defect closure of CEMR of SNADETs.

Aims & Methods

This prospective study aimed to evaluate the safety and efficacy of using only hemoclips for closure of SNADETs resected by CEMR. 21 patients from December, 2022 to March, 2023 who underwent the procedure at our center for lesions <10mm in size were included in the study. The pimary outcome was post procedural adverse events that included the rate of delayed bleeding and perforation, and ulcer dehiscence. The secondary outcomes were en bloc and R0 resection rates, complete closure rate, number of clips used, total procedure time, and duration of hospital stay. Descriptive statistics were used to summarize the outcomes.

Results

16 males and 5 females with median age of 59(38-75) years underwent CEMR for SNADETs and closure with hemoclips only. Paris classification morphology of 67.7% lesions was 0-IIa and 33.3% lesions was 0-IIc. All lesions of median size 4(2-6) mm were successfully resected en bloc. The median specimen size was 14(12-25) mm and the median number of hemoclips used for complete closure were 7(5-11). The mean resection and closure times were 5.7+1.8 and 9.3+3.9 minutes respectively. The mean total procedure time was 14.9+4.9 minutes. Complete closure rate was 100% with no dehiscence seen on check endoscopy (done one day post index procedure). Pathology revealed 42.9% of the lesions having low grade dysplasia and 57.1% having high grade dysplasia with R0 resection rate being 100%. There was no delayed bleeding or perforation. The mean duration of post procedure hospitalization was 2.2+0.9 days.

Outcomes of closure of CEMR for SNADETs with hemoclips only

Conclusion

Our single center study is the first to demonstrate an excellent safety profile for the use of only hemoclips in closing post CEMR defects of SNADETs. It is easy to perform, requires no additional accessories, and reduces procedure time and cost compared to other available methods of closure. Furthermore, in lesions under 10mm, CEMR was effective at en-bloc resection with favorable procedure time and duration of post procedural hospital stay. Larger scale studies may be warranted to confirm this method of resection for SNADETs and safety of closure technique.

References

1. Jamil LH, Kashani A, Peter N, et al. Safety and efficacy of cap-assisted EMR for sporadic nonampullary duodenal adenomas. Gastrointest Endosc 2017; 86:666-72.
2. Ohata K, Sakai E, Suzuki Y et al. Risk factors of delayed bleeding after endoscopic resection of superficial non-ampullary duodenal epithelial tumors and prevention by over-the-scope and conventional clipping. Dig Endosc 2021; 33: 390–8.

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.