Clinical Outcomes of endoscopic submucosal dissection for superficial peri-ampullary duodenal epithelial tumors

Aims Endoscopic submucosal dissection (ESD) for superficial non-ampullary duodenal epithelial tumors (SNADETs) is a minimally invasive and useful procedure for tumor control and patient quality of life. However, ESD for superficial peri-ampullary duodenal epithelial tumors (SPADET) is a more challenging and difficult procedure with a high risk of complications owing to its location near the papilla of Vater. This study aimed to clarify the safety and usefulness of ESD for SPADETs.

Methods Patients who underwent ESD for superficial duodenal epithelial tumors at our hospital between January 2015 and September 2024 were enrolled. The patients were divided into two groups: SPADET located near the papilla of Vater with margins<10 mm or invading the papilla of Vater (SPADET group) and other SNADET lesions (SNADET group). We retrospectively investigated the clinicopathological features and treatment outcomes of both the groups. As a modification of ESD for the papillary group, to shorten the exposure time to bile and pancreatic juice, most of the submucosal layer was dissected leaving the papillary area, and the papillary sphincter was resected at the end of ESD. If the papillae were involved in the suture line, bile and pancreatic duct stents were placed before the suture.

Results Of the 80 patients with 81 lesions, 19 and 62 lesions were observed in the SPADET and SNADET groups, respectively. There were no significant differences in the patient characteristics. In the SPADET and SNADET groups, tumor diameter (37 mm [13-73] vs 22 mm [7-70], p<0.01), resection time (90 min [28-135] vs 51 min [14-132], p<0.01), and suture time (37 min [7-115] vs 16 min [6-110], p<0.01) were significantly longer in the SPADET group. The complete suture rate was significantly lower in the SPADET group (84.2% vs. 98.4%, p<0.05). There was no significant difference in the choice of suture device between the two groups (clip alone/end loop/OTS-Clip=12/2/5vs34/1/27). The en bloc and R0 resection rates were comparable in both groups (100% vs.100% and 89.5% vs. 88.7%, P=0.99). In the SPADET group, 52.6% (10/19) underwent papillary resection, and 63.2% (12/19) underwent bile duct or pancreatic duct stenting. Intraoperative perforation was not observed in the both two group, and delayed perforation tended to be higher in the papillary group (16.7% vs. 3.4%, P=0.08); however, all patients were treated without surgery. No local recurrence was observed in the two groups.

Conclusions ESD for SPADET has a high en bloc resection rate and can be performed safely without intraoperative perforation. We present a video showing the ESD technique that requires papillary resection and wound suturing.

Publication History

Article published online:
27 March 2025