Special Article - Current Endoscopic Therapy in Japan
Austin J Gastroenterol. 2015;2(2): 1038.
Satohiro Matsumoto* and Yukio Yoshida
Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
*Corresponding author: Satohiro Matsumoto, Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama, Saitama 330-8503, Japan
Received: December 19, 2014; Accepted: February 23, 2015; Published: February 25, 2015
The indication of ESD (endoscopic submucosal dissection) for the treatment of these tumors remains controversial, because the procedure is technically difficult and associated with a high incidence rate of complications . While ESD may be indicated for non-ampullary duodenal tumors, including adenomas, carcinomas, and neuroendocrine tumors (NET), there is the need to determine whether ESD or endoscopic mucosal resection (EMR) might be optimal. At present, the criteria for selection between ESD and EMR vary among institutions.
The indication for ESD of duodenal tumors should be determined by assessment of the histopathology, macroscopic morphology, and diameter of the tumors. The three types of candidate lesions for endoscopic therapy are adenoma, carcinoma, and NET.
Duodenal adenomas have the potential for malignant transformation . Especially, those that are 2 cm or more in diameter and adenomas showing high-grade dysplasia on histopathology show a high likelihood of becoming malignant , and resection is preferable for such lesions. At our institution, endoscopic therapy is not selected for patients with low-grade adenomas measuring less than 1 cm in diameter; instead, such patients are followed up with regular endoscopy. We select endoscopic therapies for adenomas that are at least 1 cm in diameter or show a tendency to grow, those that are histopathologically diagnosed as low-grade adenoma, but appear red and are macroscopically suspected as cancer, etc.
In a study of 128 lesions of early duodenal cancer for which surgery or endoscopic polypectomy was performed, it was reported that none of the cases of intramucosal carcinoma showed lymph node metastasis . Complete (R0) resection is more frequently achieved by ESD than by EMR . Furthermore, en bloc resection enables accurate histopathological assessment of deep and lateral surgical margins . Thus, it seems preferable to perform EMR for lesions that can be resected en bloc by EMR and to perform ESD for lesions in which EMR is expected to result in piecemeal resection.
In regard to NET, although EMR may be well applicable in tumors measuring less than 1 cm in diameter invading the superficial layers of the submucosa, especially lesions with polypoid morphology, ESD may be useful for lesions that are difficult to resect en bloc by EMR. However, when the lower margin of a tumor lesion is widely attached to the muscle layer, ESD is associated with an extremely high risk of perforation, and the histopathological diagnosis of the deep surgical margin is also slightly uncertain; thus, surgical treatment should be considered for such cases .
The most common complication of endoscopic therapies for duodenal lesions is bleeding, which, in general, occurs within 24 hours after the operation. The frequency of bleeding after ESD is 6.7% . The incidence rate of perforation complicating duodenal ESD is 21% , which is extremely high as compared to that of perforation complicating gastric ESD. Moreover, attention should be paid not only to intraoperative perforation, but also delayed perforation due to exposure to bile or pancreatic juice. As compared to that in patients undergoing EMR, the incidence rate of perforation is significantly higher in those undergoing ESD, and the duration of postoperative hospital stay is also significantly longer .
The indications for ESD should be carefully considered. Duodenal ESD should have limitations, such as the need for its being performed by experts with abundant experience in performing the procedure.
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