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Endoscopy 2017; 49(07): 659-667
DOI: 10.1055/s-0043-105484
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic resection of large duodenal and papillary lateral spreading lesions is clinically and economically advantageous compared with surgery

Amir Klein
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
,
Golo Ahlenstiel
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
2   University of Sydney, Sydney, Australia
,
David J. Tate
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
,
Nicholas Burgess
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
,
Arthur Richardson
3   Department of Surgery, Westmead Hospital, Sydney Australia
,
Tony Pang
3   Department of Surgery, Westmead Hospital, Sydney Australia
,
Karen Byth
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
,
Michael J. Bourke
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia
2   University of Sydney, Sydney, Australia
› Author Affiliations
Further Information

Publication History

submitted 17 September 2016

accepted after revision 09 February 2017

Publication Date:
04 April 2017 (online)

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Abstract

Background and study aims Adenomas of the duodenum and ampulla are uncommon. For lesions ≤ 20 mm in size and confined to the papillary mound, endoscopic resection is well supported by systematic study. However, for large laterally spreading lesions of the duodenum or papilla (LSL-D/P), surgery is often performed despite substantial associated morbidity and mortality. We aimed to compare actual endoscopic outcomes of such lesions and costs with those predicted for surgery using validated prediction tools.

Patients and methods Patients who underwent endoscopic resection of LSL-D/P were analyzed. Two surgeons assigned the hypothetical surgical management. The National Surgical Quality Improvement Program (NSQIP), and the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) were used to predict morbidity, mortality, and length of hospital stay. Actual endoscopic and hypothetical surgical outcomes and costs were compared.

Results A total of 102 lesions were evaluated (mean age of patients 69 years, 52 % male, mean lesion size 40 mm). Complete endoscopic resection was achieved in 93.1 % at the index procedure. Endoscopic adverse events occurred in 18.6 %. Recurrence at first surveillance endoscopy was seen in 17.7 %. For patients with ≥ 2 surveillance endoscopies (n = 55), 90 % were clear of disease and considered cured (median follow-up 27 months). Compared with hypothetical surgical resection, endoscopic resection had less morbidity (18 % vs. 31 %; P = 0.001) and shorter hospital stay (median 1 vs. 4.75 days; P < 0.001), and was less costly than surgery (mean $ 11 093 vs. $ 19 358; P < 0.001).

Conclusion In experienced centers, even extensive LSL-D/P can be managed endoscopically with favorable morbidity and mortality profiles, and reduced costs, compared with surgery.

 

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