Published online Dec 26, 2020. doi: 10.12998/wjcc.v8.i24.6296
Peer-review started: August 26, 2020
First decision: September 13, 2020
Revised: September 15, 2020
Accepted: September 25, 2020
Article in press: September 25, 2020
Published online: December 26, 2020
Endoscopic submucosal dissection (ESD) has been advocated by digestive endoscopists because of its comparable therapeutic effect to surgery, reduced trauma, faster recovery, and fewer complications. However, ESD for lesions of the duodenum is more challenging than those occurring at other levels of the gastrointestinal tract due to the thin intestinal wall of the duodenum, narrow intestinal space, rich peripheral blood flow, proximity to vital organs, and high risks of critical adverse events including intraoperative and delayed bleeding and perforation. Because of the low prevalence of the disease and the high risks of severe adverse events, successful ESD for lesions of the duodenum has rarely been reported in recent years.
To investigate the efficacy and safety of ESD in the treatment of duodenal space-occupying lesions.
Clinical data of 24 cases of duodenal lesions treated by ESD at the Digestive Endoscopy Center of the Affiliated Hospital of Qingdao University from January 2016 to December 2019 were retrospectively analyzed.
All of the 24 cases from 23 patients underwent ESD treatment for duodenal space-occupying lesions under general anesthesia, including 15 male and 8 female patients, with a mean age of 58.5 (32.0-74.0) years. There were 12 lesions (50%) in the duodenal bulb, 9 (37.5%) in the descending part, and 3 (12.5%) in the ball-descending junction. The mean diameter of the lesion was 12.75 (range, 11-22) mm. Thirteen lesions originated from the mucosa, of which 4 were low-grade intraepithelial neoplasia, 3 were hyperplastic polyps, 2 were chronic mucositis, 2 were adenomatous hyperplasia, 1 was high-grade intraepithelial neoplasia, and 1 was tubular adenoma. Eleven lesions were in the submucosa, including 5 neuroendocrine neoplasms, 2 cases of ectopic pancreas, 1 stromal tumor, 1 leiomyoma, 1 submucosal duodenal adenoma, and 1 case of submucosal lymph follicular hyperplasia. The intraoperative perforation rate was 20.8% (5/24), including 4 submucosal protuberant lesions and 1 depressed lesion. The mean length of hospital stay was 5.7 (range, 3-10) d, and the average follow-up time was 25.8 (range, 3.0–50.0) mo. No residual disease or recurrence was found in all patients, and no complications, such as infection and stenosis, were found during the follow-up period.
ESD is safe and effective in the treatment of duodenal lesions; however, the endoscopists should pay more attention to the preoperative preparation, intraoperative skills, and postoperative treatment.
Core Tip: Endoscopic submucosal dissection (ESD) has been advocated by digestive endoscopists because of its comparable therapeutic effect to surgery, reduced trauma, faster recovery, and fewer complications. ESD for lesions of the duodenum is challenging due to the thin intestinal wall of the duodenum, narrow intestinal space, rich peripheral blood flow, and proximity to vital organs, such as the common bile duct and pancreas. Therefore, the duodenal lesion biopsy before ESD should be small and parallel to the fold to avoid scarring and hindering subsequent dissection. Duodenal ESD should be performed quickly to shorten the operation time and reduce delayed perforation and bleeding caused by electrocoagulation syndrome and intestinal wall edema, especially when the lesions are on the medial side of the descending segment of the duodenum because of proximity to huge arteries, the common bile duct, and pancreas tissues. The wounds after ESD should be sutured with metal clips to avoid late perforation.