Among 167 SNADETs over a 5-year period, we recorded a 22.2% rate of clinically significant AEs and found lesion size ≥ 30 mm to be the only statistically significant risk factor for AEs. Notably, the risk of IE was not associated with patient characteristics or other lesions, and currently recommended technical prophylactic measures, such as closing the resection bed with clips, had no influence on the risk of IE. The use of a monofilament collar makes it possible, thanks to increased rigidity, to better grasp a flat lesion. However, the cutting phase is faster, possibly resulting in less coagulation of the resection bed and a higher secondary bleeding rate explaining the trend although the difference is not statistically significant.
Retrospective studies have suggested that delayed bleeding occurs in 4.4-17.4% of cases after EMR of duodenal adenomatous lesions10,11,12,13,14,15,16,17, and that the risk increased with the size of the lesion and the presence of a protruding lesion (Paris 0–Is type). In the only currently published prospective study involving 110 lesions and 118 patients, delayed bleeding occurred in 18.6% of cases18. Although this high rate may be the result of the inclusion of 18% ampullary adenomas and 30% giant adenomas, it also highlights the possible underestimation of complication rates after duodenal EMR in most retrospective studies. . Aschmoneit-Messer et al., in a prospective study including 50 patients and 61 lesions, showed that prophylactic argon plasma coagulation (APC) of the resection bed decreased the risk of delayed bleeding after EMR of duodenal adenomatous lesions > 20 mm and /or in case of apparent vessels ≥ 1 mm19. However, given a delayed perforation in one of the six patients treated by APC, the safety of this approach is questionable. Lepilliez et al., in a retrospective study including 36 patients and 37 lesions, found that no delayed bleeding occurred in patients treated with prophylactic clipping or prophylactic argon plasma coagulation, or in patients treated for intrauterine bleeding. procedural. Meanwhile, delayed bleeding occurred in 21.7% of the rest of the patients16. Nonaka et al., in a retrospective study including 113 patients and 121 lesions, showed that the rate of delayed bleeding decreased from 32 to 7% in the event of prophylactic clipping (p 17. These two works, as well as others, have contributed to demonstrating that complete closure with clips, achievable in most cases for lesions less than 20 mm, is effective in preventing adverse events.20. However, in the large lesions included in our study, complete closure was only achievable in 38.9% of the lesions. Therefore, we cannot exclude that complete closure of these large lesions would have resulted in a reduction in the rate of adverse events. Therefore, the ESGE guidelines recommend prophylactic treatment of delayed bleeding by placing clips to close the mucosal defect or by non-contact hemostatic measures.5. Given the questionable stability and efficacy of hemostatic powders and gels, the most promising options for the prevention of AE after endoscopic duodenal resection rely on a change in resection technique, using cold EMR, combined with a lower rate of AE; and better closure of mucosal defects, using endoscopic suturing techniques when complete clip closure is not possible.
Although the delayed bleeding rate of 17.7% is consistent with literature data, we observed no statistically significant benefit from clipping the resection bed. This is probably explained by the large size of the resected lesions, with more than 45% of lesions > 30 mm, preventing complete closure of the resection bed with clips.
Immediate perforation, defined by a breach in the muscularis propria during endoscopic resection, occurs in 2.2 to 6% of resections10,11,12,13,14,15,16,17. Management of immediate perforations consists of closing the perforation with clips, preferably after completing the resection. Perforation usually occurs in pretreated or multiple biopsy lesions with submucosal fibrosis or insufficient submucosal injection. In our cohort, immediate perforation occurred in 2.4% of resections.
Late perforations of the duodenal wall are probably caused by multiple parameters such as thermal aggression of resection and hemostasis, but also chemical aggression by bile acids and pancreatic fluid. After EMR for duodenal adenomatous lesions, reported rates range from 1.7 to 7.4% and explain the 1% mortality associated with this procedure10,11,12,13,14,15,16,17. Our results were consistent with these figures, with no mortality, and also illustrate the feasibility of endoscopic management of delayed perforations.
According to retrospective studies, the rate of local recurrence varies from 9 to 37%10,13,14,15. It seems maximal for fragmentary resections of lesions > 20 mm. We found an overall recurrence rate of 42.5% and identified high-grade dysplasia, fragment resection and multiple resected lesions as potential risk factors. Recidivism being a secondary endpoint, we did not perform a multivariate analysis. These high figures are explained by the high proportion of resections on an ad hoc basis due to the large size of the resected lesions in our cohort.
The strengths of our study were the large number of resections, performed in consecutive patients and recorded prospectively at a single center, including large and giant lesions, with follow-up data available, allowing recurrence rates to be assessed. The main limitations are the heterogeneity of the resection tools, reflecting the number of operators involved, the retrospective analysis of the database, resulting in a loss of data, and the inclusion of patients from an expert center, resulting in a selection bias. In addition, a multivariate analysis was performed only for the primary endpoint and not for the secondary endpoints. The information concerning the location in relation to the papilla being most often missing, we were unable to analyze this parameter.
Underwater EMR (U-EMR) performed in the duodenum is a promising treatment option. Filling the duodenal lumen with water prevents overstretching of the duodenal wall and allows duodenal neoplasms to be resected without submucosal detachment. These two factors made it possible to achieve 87.5 to 100% complete endoscopic resection with a delayed bleeding rate of up to 25% and a low perforation rate.21,22,23,24,25. Endoscopic submucosal dissection allows en bloc resection rates of 75 to 100%, with 9 to 36% perforations. In addition, duodenal ESD does not lead to a decrease in the rate of local recurrences26. As multiple studies show, cold loop polypectomy appears to be a safe resection technique for duodenal lesions up to 10 mm27.28. In view of these figures, the ESGE recommends cold loop polypectomy for lesions up to 6 mm and to limit the use of duodenal endoscopic submucosal dissection to selected cases in expert centers.12,14,16,29,30.
Future measures are still experimental in 2022. Endoscopic suturing of duodenal EMR sites was described as feasible in a case series of 7 patients31. Given the size, cost, and maneuverability of available endoscopic suturing devices, endoscopic suturing of EMR sites is not cost effective. A full-thickness upper gastrointestinal resection device was performed in 8 patients with duodenal lesions32 with an excellent safety profile, but the technical feasibility and histologically complete resection rates in lesions > 20 mm are uncertain.
In conclusion, EMR for supracentimetric duodenal adenomatous lesions is associated with AEs such as delayed bleeding or delayed perforation in 22.2% of cases, particularly in lesions ≥ 30 mm. Preventive measures, such as complete closure of the mucosal defect with clips are often technically impossible in large lesions, while prophylactic coagulation of the resection bed might increase the risk of delayed perforation.
