Approach to the endoscopic resection of duodenal lesions

Table 2 Endoscopic procedures for the potential resection of elevated or sessile mucosally-based duodenal lesions (typically for duodenal adenomas)

Procedure	Appropriate lesion size	Used for non-ampullary lesions	Used for papillectomy	Piecemeal resection possible	Can be done using a duodenoscope	Degree of difficulty
Snare polypectomy (en bloc)	≤ 10 mm	Y	Y	N	Y	+
Cap-assisted EMR	≤ 18 mm	Y	N	Y	N	+++
(requires submucosal lifting)
Cap-band-assisted EMR	≤ 11 mm	Y	N	Y	N	++
Conventional EMR (with submucosal injection)	Any size	Y	Y	Y	Y	+++
Underwater EMR	Any size	Y	Y	Y	Y	+++
					(forward-viewing scope with a cap is preferred)
ESD	Any size	Y	N	N/A	N	++++
				(goal of ESD is en bloc resection)

For degree of difficulty, + denotes the easiest and ++++ denotes the hardest procedures to perform. EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection.