Feasibility of endoscopic submucosal dissection for lesions adjacent to the major papilla of the duodenum

Aims Endoscopic submucosal dissection (ESD) for superficial nonpapillary duodenal epithelial tumors (SNADETs) has a high risk of delayed adverse events due to the anatomically thin wall and direct exposure to bile and pancreatic juice. Recent advances in endoscopic closure can overcome these issues and ensure safety. However, if the lesion is adjacent to the major papilla, the incision line could extend the major papilla, which makes endoscopic closure difficult. It is unclear how these lesions should be treated and whether safety can be ensured. This study aimed to evaluate the feasibility of ESD for SNADETs adjacent to the major papilla.

Methods This study design was a single-center, retrospective, observational study. We reviewed the cases of duodenal ESD between January 2020 and April 2024. Inclusion criteria were the lesions that didn't involve the major papilla but were within 10 mm proximity to it. We evaluated clinical characteristics, ESD outcomes, positional relation between the incision line and the major papilla, closure outcomes, and delayed adverse events.

Results Twenty-eight of 475 duodenal ESD cases were included in the study. The median size was 30 mm [range: 8-101]. En-bloc resection was achieved in all cases, and intraoperative perforation was observed in one case. Complete closure was not achieved in three cases because the resection extended into the major papilla in two cases, and the lesion was too large in one case. Although endoscopic nasobiliary bile duct and pancreatic drainage was performed to prevent delayed bleeding and perforation in these three cases, post-endoscopic retrograde cholangiopancreatography pancreatitis was observed in three cases, and delayed bleeding was observed in one case. The major papilla was preserved in the remaining 25 patients (12 cases had the major papilla in contact with the incision line), and complete closure was achieved in all cases. However, delayed adverse events were observed in five of 25 (20%) (two cases of acute pancreatitis, one case of delayed bleeding, and two cases of delayed perforation). Among the 25 cases, the percentage of cases where the incision line was in contact with the major papilla was significantly higher in those with delayed adverse events than those without.[100% vs. 35% p=0.015]. All 28 cases didn't require emergency surgery, and the median hospital stay after ESD was 5 days [range: 3-26].

Conclusions Although the cases of the major papilla resected or in contact with the incision line had a high delayed adverse events rate regardless of the complete closure, all cases achieved en-bloc resection without emergency surgery, which suggested the feasibility of this procedure.

Publication History

Article published online:
27 March 2025