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192
Fig. 12.2 Fifteen
millimeter sessile polyp in
the second portion of the
duodenum consistent with
non-ampullary duodenal
adenoma
Fig. 12.3 Non-lifting after
submucosal injection. In
this setting, the adenoma
was non-lifting secondary
to scarring from prior
resection. Photo courtesy
of Brooke Glessing, MD
C. Vozzo and A. Faulx
Any lesions with suspected invasive neoplasia are not suitable for endoscopic
resection. Biopsy sampling should be limited to the surface of the polyp to avoid
submucosal scarring and brosis that will make endoscopic resection difcult [10].
Endoscopic Assessment ofAmpullary Adenomas
Ampullary adenomas are adenomas involving the major papilla and can be sporadic
or related to a polyposis syndrome. Unlike non-ampullary polyps, ampullary lesions
may cause symptoms due to their location including jaundice, abdominal pain, duodenal obstruction, pancreatitis, or bleeding [3]. It can be difcult to distinguish
12 Endoscopic Duodenal Resection
193
benign, pre-malignant, and malignant lesions around the ampulla. Features of concern include bleeding, rmness, and non-lifting after submucosal injection. Forceps
biopsy and histological examination are mandatory in the diagnosis of ampullary
tumors prior to considering resection approach [5, 11]. Diagnostic accuracy of biopsies is variable (ranging from 38% to 85%) and should be minimized by sampling
tissue at least 10days following sphincterotomy to minimize cytologic atypia that
can occur and obtaining at least six biopsy samples [5]. While pancreatitis is possible following biopsy, overall this is regarded as low risk with a good safety prole [12].
Several factors should be noted prior to considering surgical or endoscopic resection of an ampullary lesion. This includes staging, assessment for intraductal extension of adenoma, and presence of pancreas divisum. Multiple modalities have been
studied in literature and include transabdominal ultrasound, computed tomography
(CT), magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and intraductal US (IDUS). European Society of Gastrointestinal Endoscopy (ESGE)
guidelines support the use of EUS and MRCP for staging given their marginally
higher accuracy, reproducibility, and safety [11].
Sporadic ampullary tumors should be referred for surgical management if the
lesion size is larger than 2–3cm or intraductal extension exceeds 1–2cm [5, 11].
Figure12.4 is an ampullary adenoma with moderately differentiated adenocarcinoma in a background of adenomatous change with high-grade dysplasia.
Endoscopic Assessment inPolyposis Syndromes
Assessment of duodenal polyps (ampullary and non-ampullary) in adenomatous
polyposis syndromes begins at age 25years. The Spigelman classication for duodenal polyps helps predict cancer risk and outlines surveillance intervals (Table12.3)
[13]. Stage 0 patients will require repeat endoscopy in 4years, stage I will require
repeat endoscopy in 2–3years, stage II will require repeat endoscopy in 1–3years,
and stage III will require repeat endoscopy in 6–12months. Patients with stage IV
should have surgical evaluation [14].
.
194
Fig. 12.4 Ampullary
adenoma ultimately found
to have invasive
moderately differentiated
adenocarcinoma. Photo
courtesy of Brooke
Glessing, MD
Table 12.3 Spigelman classication
Points
Criteria
Polyp number 1–4 5–20 >20
Polyp size (mm) 1–4 5–10 >10
Histology Tubular Tubulovillous Villous
Dysplasia Mild Moderate Severe
Stage 0=0 pts; stage I=1–4 pts, stage II=5–6 pts, Stage III=7–8 pts, stage IV=9–12 pts
Adapted from Spigelman etal. [13]
1 2 3
C. Vozzo and A. Faulx
Resection Techniques
Sporadic Non-ampullary Adenomas: Cold Snare Polypectomy
Resection technique is similar to that of polypectomy in the right colon due to thinness of the duodenal wall. Cold snare polypectomy is recommended for small
(<6mm lesions). Hot snare polypectomy has been associated with delayed bleeding, perforation, and post polypectomy syndrome and therefore not preferred [15].
Technique: A snare trap is placed on a suction device prior to polypectomy. The
lesion should be oriented at the 5-o’clock position. The snare is opened and positioned over the lesion. To obtain adequate tissue apposition, a combination of scope
tip deection and advancement of the snare is advised. One millimeter of normal
tissue around the lesion helps to ensure lesion capture. The lesion is cut by closing
the snare and returning the snare into the suction channel to facilitate easier retrieval
of the polyp. The polypectomy site is examined carefully. A submucosal cord is
often visible and need not be further resected. Bleeding is normal but should resolve
12 Endoscopic Duodenal Resection
spontaneously after some time. If bleeding continues, consider placement of a
hemostatic clip [16].
195
Sporadic Non-ampullary Adenomas: EMR
Conventional EMR: Conventional EMR is used as rst line for endoscopic resection
of non-cancerous large non-ampullary duodenal adenomas (>6mm).
Technique: This is usually completed with a forward-viewing endoscope tted
with a distal cap, yet a side-viewing duodenoscope may be required for lesions in
the medial part of the descending duodenum. Dye or virtual chromoendoscopy may
be used to outline the lesion prior to resection and is used to separate the muscularis
propria from the lesion to reduce the chance of perforation. Marking the lesion with
a snare tip cautery is recommended. Submucosal injection can be performed with
dye saline solution or specic macromolecular solution. The volume injected is
dependent on the size of the lesion, and repeat injection may be required if the cushion dissipates. Epinephrine can be added to the solution to prevent post-procedural
bleeding (1:100,000 dilution). Snare size should be selected based on lesion size
(usually 10mm, 15mm, or 25 mm) and should be enhanced with electrocautery.
The polyps may require piecemeal resection (overlapping snare resections) if the
lesion is larger than 2cm [17].
Other emerging EMR techniques include cap-assisted EMR, cap-band-assisted
EMR, and underwater EMR. Cap-assisted EMR and cap-band-assisted EMR can be
used specically for lesions that do not lift well or are difcult to capture with a
snare [18]. In both of these techniques, the polyp is suctioned into cap and resected
with a dedicated snare. Underwater EMR is an emerging technique that employs
water immersion (rather than air or carbon dioxide). The lumen is less distended
during polypectomy; therefore, there is no need for submucosal injection because
the wall maintains its innate thickness [1]. Water acts to “oat” the lesion and
decrease the risk of capturing muscle in the snare.
Sporadic Non-ampullary Adenomas: ESD
The use of endoscopic submucosal dissection (ESD) in non-ampullary duodenal
lesions is generally not supported in the guidelines because of the high risk of perforation [5, 15]. The higher risk of perforation in the duodenum is related to the thin
muscularis propria layer. Retrospective studies comparing EMR vs ESD show a
better en bloc resection rate with ESD but no difference in long-term outcomes and
a higher rate of intra- and post-procedural perforation [19–21].
Technique: A high-denition therapeutic gastroscope with a single large
(3.7mm) instrument channel is the preferred endoscope for ESD. Prior to beginning
the resection, the borders of the lesion should be marked with electrocautery. A long
196
lasting lifting agent is then injected into the submucosal layer. The mucosa is
incised, and the perimeter of the lesion is cut using a specialized electrosurgical
knife. The submucosa is further injected and then dissected along this plane in a
freehand manner [22].
C. Vozzo and A. Faulx
Sporadic Non-ampullary Adenomas: Full-Thickness Resection Device
The feasibility of endoscopic full-thickness resection (EFTR) of duodenal lesions
with a full-thickness resection device has been described in both the upper and
lower GI tract [23, 24]. In a study of duodenal EFTR, the bleeding risk is similar to
that of EMR without any observed perforations [25]. Randomized trials are required
to directly compare EMR to EFTR in the duodenum. It should also be noted that
ampullary adenomas cannot be resected via this approach as it would lead to
obstruction of the bile and pancreatic ducts.
Ampullary Adenomas: Endoscopic Papillectomy
Commonly referred to in the literature as an ampullectomy, but more properly
described as endoscopic papillectomy, refers to the removal of the major papilla via
endoscopic means. The goal of endoscopic papillectomy is en bloc resection, allowing margins to be assessed.
Technique: A side-viewing duodenoscope is utilized to optimally visualize the
papilla during endoscopic papillectomy. Lesions that spread beyond the ampulla
may require submucosal injection; otherwise, injection should be avoided due to a
ballooning effect that occurs around the adenoma given the natural tethering of the
pancreatic and biliary orices [26]. The general approach for resection is the fulcrum technique. The snare is opened partially inside the working channel. The tip of
the snare is at the apex of the lesion/ampulla and is aligned slightly to the right of
the lesion to avoid losing scope control. The snare is fully opened, and duodenoscope is pushed distally over the lesion. Once fully captured, the snare is closed
completely. The snare should be moved back and forth to conrm that deeper layers
have not been encircled prior to resection. The lesion should be cut with electrocautery, endocut mode with standards for polypectomy [27]. The specimen should be
captured with snare quickly to ensure it does not migrate distally. Post polypectomy
inspection should examine for bleeding, perforation, and en bloc resection.
Pancreatic duct stent following endoscopic papillectomy is supported to help prevent post-procedural pancreatitis in addition to rectal indomethacin [11]. Some
endoscopists prefer injection of contrast with methylene blue prior to ampullectomy
to help locate pancreatic duct orice after resection. Biliary cannulation is only
12 Endoscopic Duodenal Resection
Fig. 12.5 Completed
ampullectomy. Cannulation
of biliary orice completed
post-ampullectomy;
however, PD could not be
located. Photo courtesy of
Amitabh Chak, MD
197
suggested if there is concern for perforation, bleeding, or suspected delay in biliary
drainage [28]. Completed ampullectomy can be seen in Fig.12.5.
There are some notable modications to standard endoscopic papillectomy.
Notably, balloon-catheter-assisted endoscopic snare papillectomy is a useful technique which is advantageous for at lesions. A balloon catheter and snare are
inserted into the bile duct via the accessory channel of a duodenoscope, and snare
resection was performed while pulling the expanded balloon toward the lumen [29].
Underwater EMR of papilla has been described in the instance of a neuroendocrine
tumor [30]. Finally, in some instances, the endoscopist may opt to cannulate the
pancreatic duct and leave an insulated wire prior to papillectomy given how challenging it can be to locate and cannulate the PD after resection is complete [31].
Post-procedural Care, Adverse Events, andRecurrence Rates
The post-procedural level of care following upper GI endoscopy for a duodenal
resection is largely dependent on the modality of resection. In the recovery area, the
patient is monitored for sedation and procedural-related complications which may
include bleeding, perforation, infection, or pancreatitis. The patient can usually be
discharged on the same day of the procedure once vital signs are stable and the
patient is alert. The patient should be counseled against driving, operating heavy
machinery, or signing legal documents on the day of their procedure. The patient
should be discharged home with a driver.
Post-procedural management after endoscopic papillectomy is more aggressive
due to the high risk nature of the procedure and likelihood of adverse events. Patients
198
should be considered for hospital admission if they have multiple medical comorbidities, limited access to care, or large lesion resection [5].
While endoscopy with polypectomy carries an exceptional safety prole, for the
reason discussed earlier in this chapter, duodenal resections have higher rates of
bleeding and perforation compared to other areas of the GI tract. Each resection
modality has a different adverse event rate as discussed below.
C. Vozzo and A. Faulx
Sporadic Non-ampullary Adenomas: Cold Snare Polypectomy
Cold snare polypectomy for small duodenal polyps (<6 mm) can be performed
without difculty and low rate of reported complications. Although very little data
exist in regard to the procedural outcomes and recurrence rates, a single prospective
study by Maruoka etal. examined outcomes for cold forceps or cold snare polypectomy for duodenal polyps <6mm in size. There were no complications (delayed
bleeding or perforation). The recurrence rate of adenomas at 3months was also
zero [32].
Sporadic Non-ampullary Adenomas: EMR
A number of retrospective and a single prospective study have examined the adverse
event rate associated with non-ampullary duodenal polyp EMR. Immediate bleeding rates range from 0% to 43%, and immediate perforation rates range from 0% to
5.5%. The delayed complications of bleeding and perforation range from 0% to
17% and 0% to 4.4%, respectively. Recurrence rates after resection ranged from 0%
to 37%. The rate of adverse events increased with increasing lesion size [17].
Intraprocedural bleeding should be managed immediately with cautery (snare tip or
coagulating forceps). Clips may be used but can be challenging to place with a duodenoscope and may obscure the remainder of the resection eld. Delayed bleeding
can occur up to 7days following the procedure and should be managed with emergent upper endoscopy [10]. Immediate perforations can usually be managed endoscopically. Delayed perforations can occur following the procedure and usually
related to thermal damage to the muscular propria. These are difcult to manage and
requires a multidisciplinary discussion with the goal to either observe versus close
the defect surgically or endoscopically depending on anatomical location (peritoneal vs. retroperitoneal) and severity of patient’s clinical condition. These are the
most feared complications because they carry a 1% mortality rate [10].
Recurrence rates following EMR of non-ampullary adenomas vary widely in the
literature from 0 to 37% [10, 33, 34]. A single prospective study by Probst etal.
found a recurrence rate of 20% of duodenal adenomas ranging from 4 to 70mm
(mean 15mm) with a complete resection rate of 94% on initial EMR after 48months
of follow-up [35].
12 Endoscopic Duodenal Resection
199
Sporadic Non-ampullary Adenomas: ESD andEFTR
As discussed previously, ESD is generally avoided due to high complication rates.
Notably, 9–36% risk of perforation and 2–15% rate of emergency surgery. Although
ESD may provide a higher en bloc resection rate, safety should be considered over
this nding and should only be utilized at expert centers in select cases.
EFTR has limited data yet has revealed a favorable adverse event rate. Prior studies reported a 16–20% minor-moderate bleeding rate, but no major bleeding events
or perforations [24, 25]. With this newer device, data in the duodenum had been
limited. Bauder etal. examined recurrence following EFTR at 12months and found
recurrence in 2/19 cases [25].
Endoscopic Papillectomy
Endoscopic papillectomy carries a similar adverse event prole to that of endoscopic retrograde cholangiopancreatography. A systematic review and meta- analysis
by Spadaccini etal. included 29 studies with 1751 patients undergoing ampullectomy found an overall adverse event rate of 25% [36]. Adverse events may be early
(pancreatitis, bleeding, and perforation) or delayed (papillary/biliary stenosis or
duodenal luminal stenosis). Mortality is rare and reported to be 0.3% [27].
Adverse events may be effectively minimized and/or managed with prophylactic
endoscopic hemostasis with either clip or cautery to high-risk bleeding areas. In
addition, rectal indomethacin and pancreatic duct stent placement can be performed
to reduce the risk of pancreatitis. Finally, immediate bleeding may occur, and the
endoscopist should be prepared to employ standard techniques for hemostasis and
include interventional radiology/angiography for hemorrhage refractory endoscopic
means [11].
Recurrence rates in a 2020 systematic review with pooled analysis included 14
studies with at least 50 patients and found a pooled recurrence rate of 12% at
10–85months [36]. Recurrence rates in patients with FAP may be higher, 58% or
14/24 patients in a single 10-year retrospective study [37].
Surveillance
Surveillance strategies following endoscopic resection of non-ampullary and
ampullary tumors are lacking. A guidelines supported surveillance strategy is outlined in Table12.4.
200
Table 12.4 Surveillance guidelines for duodenal adenomas
ASGE [5] ESGE [11, 15]
Ampullary
adenoma
Non-ampullary
adenoma
Both societies support that a screening colonoscopy be offered to patients who have duodenal or
ampullary adenomas
Initial: 1–6months
Every 3–12months for 2years
OR
Follow CRC surveillance guidelines
No interval provided
Individualized based on adequacy of
resection, dysplasia, underlying
comorbid conditions
Initial: Within rst 3months
Second: 6–12months
Yearly×5years
Initial: 3months
Second: 1year
Then individualized based on size/
dysplasia, villous component, and
patient factors
C. Vozzo and A. Faulx
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