Approach to the endoscopic resection of duodenal lesions

Table 1 Types and characteristics of various duodenal lesions that can be encountered on upper endoscopy

Type of duodenal lesion	Duodenal wall layer	Malignant potential	Requires resection	Amenable to endoscopic resection
Lipoma	Subepithelial	No	No	Possible
Gastrointestinal stromal tumors	Subepithelial	Yes	Yes	Possible
				(for small lesions); often requires surgery
Carcinoids	Subepithelial	Yes	Yes	Possible
				(for rare, isolated lesions); often requires surgery
Brunner’s gland “adenomas” or hamartomas	Mucosal	No	If patients are symptomatic	Yes
Solitary Peutz-Jeghers polyps	Mucosal	Yes	Yes	Yes
Adenoma	Mucosal	Yes	Yes	Yes

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.