Comparative analysis of ESD versus EMR in a large European series of non-ampullary superficial duodenal tumors

Abstract

Background and study aims The choice of endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) in non-ampullary superficial duodenal tumors (NASDTs) is challenging and the benefits of ESD remain unclear. The aim was to comparatively analyze the feasibility, outcomes and safety of these techniques in these lesions. Patients and methods This is an observational and retrospective study. All consecutive patients presenting with NASDTs who underwent EMR or ESD between 2005 and 2017 were included. The following main outcomes were comparatively evaluated: en-bloc and complete (R0) resection rates, and local recurrence. Secondary outcomes were perforation and delayed bleeding. Results One hundred sixty-six tumors in 150 patients (age: 66 years, range: 31 – 83, 42.7 % males) were resected by ESD (n = 37) or EMR (n = 129) and included. The median procedure time (81 vs. 50 min, P = 0.007) and tumor size (25 vs. 20 mm, P = 0.01) were higher in the ESD group. The global malignancy rate was 50.3 %. There were no differences in en-bloc resection (29.7 % vs. 44.2 %, P = 0.115), complete resection (19.4 % vs. 35.5 %, P = 0.069), and local recurrence (14.7 % vs. 16.7 %, P = 0.788) rates. Tumor size was associated with recurrence (28 vs. 20 mm, P = 0.008), with a median follow-up of 6.5 months. Focal recurrence (n = 22, 13.3 %) was treated endoscopically in 86.4 %. En-bloc resection in the ESD group was comparable in large ( ≥ 20 mm) and small lesions (27.6 % vs. 37.5 %, P = 0.587), while this outcome decreased significantly in large lesions resected by EMR (17.4 % vs. 75 %, P < 0.001). Nine perforations were confirmed in 6 lesions (16.2 %) resected by ESD and 3 (2.3 %) by EMR ( P = 0.001). Endoscopic therapy was successful in all but 1 patient (88.9 %) presenting with a delayed perforation. Conclusions ESD may be an alternative to EMR and surgery in selected NASDTs, such as large duodenal tumors where EMR achieves low en-bloc resection rates and the local recurrence may be higher. However, this technique may have a higher risk of perforations.

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement – Update 2020

“…This is remarkably higher than for ESD performed in the stomach or the colon [165]. Duodenal ESD carries a higher risk of perforation than duodenal EMR (16.2 % vs. 2.3 % in a recent series of 150 patients, P = 0.001) [166], but ESD is performed only for specific RECOMMENDATION ESGE suggests that risk factors for nonperiampullary duodenal iatrogenic perforation include ERCP in patients with Billroth II reconstruction, EMR, and particularly ESD. Risk factors for jejunoileal iatrogenic perforation related to enteroscopy include stricture dilation or patients having altered anatomy or having inflammatory bowel disease being treated with steroids.…”

Pathologic evaluation of endoscopically resected non-ampullary duodenal lesions: a single center experience

“…As for the West, the contribution to the literature is relatively recent: only a handful of duodenal ERs were reported recently (22)(23)(24), yet series with comparable sizes (i.e. n=166 duodenal ERs in Pérez-Cuadrado-Robles et al's study) are being published from specialized referral centers (25,26). The main reason for this is that, similar to other sites of the gastrointestinal tract, the western experience with duodenal ESD and EMR was limited compared to the Far East (22)(23)(24)(27)(28)(29)(30)(31)(32), due to flat learning curve of these techniques and lack of training facilities for the endoscopists in the west (17,(33)(34)(35).…”

Endoscopic mucosal resection vs endoscopic submucosal dissection for superficial non-ampullary duodenal tumors

“…The procedure for EMR has been previously described in detail[ 9 , 13 ]. In brief, the procedure for EMR involves a submucosal injection, followed by mucosal resection using an electrocautery snare (Figure 1A and B ).…”

“…The procedure for ESD has been previously described in detail[ 9 , 13 , 21 ]. In brief, circumferential marking dots were placed by using the tip of an endo-knife.…”

“…However, the standard procedure for endoscopic resection remains controversial. In addition, there are limited data regarding the comparison between the two procedures of ESD and EMR[ 9 , 11 - 13 ]. No randomized-controlled trial till date has compared ESD and EMR owing to various reasons, including patient recruitment, especially the limited number of endoscopic resections performed for SNADETs in each institution.…”