Challenging underwater endoscopic mucosal resection of duodenal adenoma successfully achieved with combination of therapeutic pediatric colonoscope and retroflexion

Nonampullary duodenal adenomas are rare, detected in only 0.1%–0.4% of patients undergoing esophagogastroduodenoscopy (EGD) [1]. The European Society of Gastrointestinal Endoscopy (ESGE) recommends that all duodenal adenomas should be considered for endoscopic resection, as progression to invasive carcinoma is highly likely [2]. Endoscopic resection has been a first choice of treatment for duodenal adenomas, but the method has not been standardized [3]. To overcome the practical difficulty of conventional endoscopic mucosal resection (EMR), underwater endoscopic mucosal resection (UEMR) has recently been developed. UEMR seems to have significantly higher R0 resection rates and lower post-procedural bleeding rates than EMR. Moreover, it seems safer than conventional EMR and has been associated with a lower incidence of recurrences [4] [5].

We report a case of a 63-year-old patient hospitalized after multiple episodes of biliary cholangitis. The endoscopic retrograde cholangiopancreatography (ERCP) procedure showed the presence of a potentially adenomatous lesion located proximal to the papilla ([Fig. 1]). Biopsies confirmed high grade dysplasia.

Fig. 1 Duodenal adenoma partially involving a periampullary diverticulum.

The adenoma was first approached using a duodenoscope. The lesion measured approximately 20 to 25 mm and was partially located inside a diverticulum. A piecemeal cold snare mucosectomy was performed, combining 15- and 10-mm snares. To reach a remnant part of the lesion impossible to access with the duodenoscope, we used a pediatric therapeutic colonoscope to achieve the resection. The mucosectomy was completed by a combination of different strategies: the underwater technique allowed keeping the remnant adenoma floating, but stability was obtained thanks to a retroflexed position of the scope in the second duodenum. Finally, we obtained a macroscopically complete resection ([Fig. 2], [Video 1]). No immediate or delayed adverse events occurred and histological examination revealed high grade dysplasia. A 4-month follow-up showed no recurrence.

Fig. 2 Macroscopically complete resection of the adenoma.

Challenging resection of a duodenal adenoma successfully achieved by combining the use of underwater endoscopic mucosal resection, a therapeutic pediatric colonoscope, and retroflexion.Video 1

An underwater strategy combined with retroflexion can be a way to obtain complete endoscopic resection when access to a duodenal adenoma is hampered due to its periampullary diverticular location.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Seifert E, Elster K, Gelbmann CM. et al. Prospective study of prevalence and endoscopic and histopathologic characteristics of duodenal polyps in patients submitted to upper endoscopy. Scand J Gastroenterol 1994; 29: 483-486
• 2 European Society of Gastrointestinal Endoscopy (ESGE) Guidelines Committee. ESGE Guideline: Endoscopic management of duodenal tumors 2021. https://www.esge.com/assets/downloads/pdfs/guidelines/2021_a_1442_2395.pdf
• 3 Yamasaki Y, Uedo N, Takeuchi Y. et al. Current status of endoscopic resection for superficial nonampullary duodenal epithelial tumors. Digestion 2018; 97: 45-51
• 4 Morais R, Amorim J, Medas R. et al. Underwater endoscopic mucosal resection vs conventional endoscopic mucosal resection for superficial nonampullary duodenal epithelial tumors in the western setting. Clin Gastroenterol Hepatol 2024; 2024: S1542-3565(24)00485
• 5 Okimoto K, Maruoka D, Matsumura T. et al. The utility of underwater endoscopic mucosal resection for nonpolypoid superficial nonampullary duodenal epithelial tumors ≤20 mm. Gastrointest Endosc 2021; 95: 140-148

Publikationsverlauf

Artikel online veröffentlicht:
10. Dezember 2024