NON-AMPULLARY SPORADIC DUODENAL ADENOMAS - TIME FOR A CONSENSUS ON ENDOSCOPIC RESECTION?

Aims Sporadic duodenal adenomas (SDAs) are a rare but important endoscopic finding due to their malignant potential. Although endoscopic resection (ER) is generally advocated this carries significant risk related to the relatively thin, vascular and fixed duodenal wall. The lack of guidelines related to SDAs leads to variability in their management with potential implications for patient outcomes.

This study aimed to evaluate current practice regarding the management of non-ampullary SDAs and assess the need for a consensus.

Methods 40 internationally renowned advanced endoscopists from multiple international centres were surveyed regarding their management of non-ampullary SDAs. 12 questions investigating factors influencing whether to offer ER, pre-ER work-up, procedural risk and post-ER management were evaluated.

Results The survey was completed by 19 endoscopists with 18 confirming they endoscopically manage non-ampullary SDAs. Most endoscopists offered ER on a case-by-case basis with patient age (72%), comorbidities (44%) and lesion size (39%) reported as integral to decision-making. No guidelines were used by 94% but multi-disciplinary team discussion prior to ER was arranged routinely by 67% and in select cases by 22% of endoscopists. Endoscopists completed further investigation pre-ER including endoscopic ultrasound (39%) and cross-sectional imaging (22%). The degree of risk involved in duodenal resection quoted to patients including haemorrhage (range 1-50%, median 15%) and perforation (range 1-10%, median 3%) was variable.

Anti-coagulation and anti-platelets were restarted a median of 3 days (IQR 2-7 days) following ER. Post-procedural proton pump inhibitors were routinely prescribed by 94% of endoscopists however therapy duration was variable (median 29 days, IQR 14-30 days). Post-procedure patients were admitted routinely by 39% and in specific cases by 56% of endoscopists.

Conclusions There is widespread variability in the pre- and post-procedural management of non-ampullary SDAs in major international centres. There is a need to develop a consensus of opinion to help standardise the management of non-ampullary SDAs.