Keywords
endoscopic full-thickness resection - FTRD - duodenum - duodenal adenoma
Introduction
Adenomas in the duodenum can develop spontaneously or have an association to hereditary
syndromes. They can develop into malignant adenocarcinomas, following the adenoma–carcinoma
sequence, shown in colorectal adenomas.[1] About 5% of duodenal adenomas progress into carcinomas, therefore a resection should
be performed.[1] Removal of subepithelial tumors in the duodenum should be done if there are symptoms
(e.g., bleeding) or suspicion of malignancy. Surgical resection has a higher morbidity
versus endoscopic resection.[2] Nevertheless, endoscopic resection of those lesions has a significant risk of complications
such as perforation or bleeding.[3]
[4]
Endoscopic full-thickness resection (EFTR) using the full-thickness resection device
(FTRD, Ovesco Endoscopy AG, Tuebingen, Germany) has been reported to be effective
and safe in the colorectum.[5]
[6] Technical success of EFTR in the duodenum has been shown in previous studies.[7]
[8] The new gastroduodenal FTRD (Ovesco Endoscopy AG, Tuebingen, Germany) was recently
Communauté Européenne (CE) for EFTR of duodenal lesions. Compared with the colonic
FTRD the diameter is 19.5 mm and has an integrated guide wire and balloon for dilatation.
We now present the case of a resection of a recurrent nonlifting duodenal adenoma
using the new gastroduodenal FTRD.
Case Report
A 37-year-old white man was admitted to our hospital for endoscopic removal of a recrudescent
adenoma. The adenoma in the flexura duodeni inferior had a central scarred retraction
and biopsy-proven low-grade intraepithelial neoplasia (IEN). An endoscopic mucosal
resection (EMR) was performed 6 and 4 months before presentation at our institution.
The patient did not have any symptoms. Medical history contained hypertension and
an episode of depression. Physical examination and laboratory workup did not show
any pathology. The patient gave written informed consent.
Before resection, the margins of the 10-mm adenoma were marked with argon-plasma coagulation
(APC) with a standard gastroscope. Then we switched to the gastroduodenal FTRD. After
balloon dilatation of the upper esophageal sphincter (UES) of 20 mm, a passage with
the FTRD system was not possible. No relevant mucosal damage was detected. The patient
was discharged without pain or bleeding signs.
A new attempt was done 2 months later. After boogying on 17 to 19 mm with bougies,
the endoscope with FTRD cap was used. After balloon dilatation of the upper sphincter
of the esophagus of 20 mm, a passage with the FTRD system was again not possible.
The pressure was increased and after switching the patient into supine position, the
passage was eventually successful. The endoscope was then advanced into the duodenum.
The grasping forceps were advanced through the working channel. The lesion was pulled
into the cap to incorporate a double, full-thickness layer of the duodenal wall. The
over-the-scope clip (OTSC) was then deployed, and the tissue above the clip was immediately
resected with the snare ([Figs. 1]
[2]). The resected adenoma was retrieved. There were no signs for bleeding or perforation.
A control gastroscopy one day after showed a correctly placed OTSC. A minor contact
bleeding was treated by APC. The histological workup of the specimen (28 mm × 22 mm)
showed a 3-mm tubular adenoma with low-grade IEN and complete (R0) resection. The
patient was discharged after 2 days without any further complications.
Fig. 1 Illustration of the FTRD procedure. (1 and 2) Grasping forceps are advanced through the working channel of the endoscope. (3) The target lesion is grasped and pulled into the cap. (4) The OTSC is deployed and creates a full-thickness plication of the gastrointestinal
wall. (5) The pseudopolyp is resected above the OTSC with the preloaded snare (Courtesy of
Ovesco Endoscopy AG, Tuebingen, Germany, with permission). FTRD, full-thickness resection
device; OTSC, over-the-scope clip.
Fig. 2 Full-thickness resection of an adenoma in the duodenum: (A) marks around the adenoma; (B) grasping the adenoma; (C) correctly placed OTSC; (D) control after 3 months with OTSC in situ and cicatricial tissue. OTSC, over-the-scope
clip.
Follow-up
A gastroscopy 10 weeks after the EFTR showed no recurrence of the adenoma. The OTSC
was still in situ. There were no adverse events.
Discussion
Compared with the colon, the duodenum has a special anatomy making endoscopic resection
of adenomas or subepithelial tumors more difficult. The duodenal wall is thinner than
in the colon, the risk of bleeding is higher, and it is less flexible due to its fixation
in the retroperitoneum. However, endoscopic resection of lesions has a lower morbidity
than the surgical approach.[2]
EMR is the standard procedure for resection of duodenal nonampullary adenomas. Success
rates for complete removal is high.[2] The risk of periprocedural bleeding is up to 25%, with delayed bleeding up to 12%.[3]
[9] Moreover, the risk of perforation is up to 5%.[9] In comparison with endoscopic submucosal dissection (ESD) in the duodenum, the risk
of perforation is up to 35%, for this reason duodenal ESD is not recommended.[10] EFTR is another reasonable technique for resection of nonlifting adenomas or submucosal
tumors. The FTRD in the colorectum has proven its efficacy with acceptable complication
rates.[6]
[8]
FTRD in the duodenum has shown promising results in two previous studies including
24 patients in total with “difficult” adenomas (such as adenomas with nonlifting sign)
or subepithelial tumors.[7]
[8] Minor bleeding occurred in approximately 20% of patients, no major bleeding or perforation
was detected. Complete resection (R0) was achieved in 69.5%.
We report about a case of successful resection of a duodenal adenoma using the new
gastroduodenal FTRD (Ovesco, Tuebingen) which was recently CE-labeled. Its outer diameter
is 19.5 mm that is 1.5 mm thinner than the colonic FTRD. A limitation to FTRD in the
upper gastrointestinal tract is the need for balloon dilation of the UES and pylorus
to allow passage of the device. The passage of UES and pylorus is also the most challenging
part when using the gastroduodenal FTRD in the upper gastrointestinal tract. Therefore,
a guide wire and balloon for dilatation are integrated. Despite the lower diameter,
passage might not be possible as we described in our case. Shifting to supine position
and using a higher pressure for dilatation may enable passage, although the risk of
injury or perforation seems to be higher. An elective removal of the OTSC to our experience
is not necessary. However, if complications occur, such as luminal obstruction, clipping
of extraluminal tissues, or ulceration of the surrounding area or patients’ discomfort,
the OTSC should be removed.
Due to a limited number of patients treated with FTRD in the duodenum, the incidence
of complications cannot be evaluated properly. Therefore, more studies are needed.
The size of the lesions should not exceed 25 mm because the risk of nonsuccessful
resection rises with the lesion size.[8] That limits the use of FTRD in larger flat adenomas extending over several folds.
In comparison to EFTR in the colorectum, lesions up to 30 mm could be resected with
sufficient success.[6] It is not possible to resect tumors in the ampullary duodenum via FTRD due to the
risk of clipping the common bile duct. We strongly recommend localizing the papilla
before EFTR and to make sure that there is a distance of at least 20 mm to the papilla.
Conclusion
In conclusion, the gastroduodenal FTRD in the duodenum is a promising new device which
makes it possible to resect lesions not suiting for EMR and thus to avoid surgery.
Randomized-controlled trials are needed to evaluate the safety and success of the
gastroduodenal FTRD.
