ENDOSCOPIC RESECTION OF WIDESPREAD ADENOMATA OF THE PAPILLA AND SMALL-INTESTINE AS ORGAN PRESERVING MINIMALLY INVASIVE INTERVENTION USING ESD OR ESD/EMR.PRELIMINARY RESULTS FROM A EUROPEAN CENTER

Aims:

Most duodenal adenomata can be resected endoscopically using EMR. However, a considerable number of widespread lesions are still removed surgically with a considerable morbidity and mortality. The challenge of endoscopic resection in the duodenum consists in the thin duodenal wall. Lesions distally to the papilla have a high risk of secondary perforation due to aggressive pancreatic and biliary juice.

Methods:

Within the last two years we performed over 200 ESD-resections in our hospital. In 18 cases a resection in ESD-or combined ESD/EMR-technique was performed in the small intestine i.e. duodenum/papilla, jejunum and once jejunal-pouch after procto-colectomy. In selected cases with lesions located at the level or distally to the papilla and widespread resection we inserted a modified polyurathan vacuum sponge with a continuous negative pressure to suck off biliary and pancreatic fluid.

Results:

From 28.08.2016 to 20.08.2018 we performed 18 resections in 16 patients with laterally spreading D3-/D2-papillary or extrapapillary duodenal adenomata > 2 cm in size (2,2 × 1,8 cm to 7,5 × 3,7 cm). In 7 cases a protective duodenal vacuum sponge was inserted. In 16 of 18 cases a macroscopic complete resection was performed. In 2/18 cases a 50% partial resection of the two bulky lesions in D2/D3 with LGIEN was performed intentionally in the two elderly patients at elevated operative risk. In total 11 en-bloc ESD- resections were carried out with R0 resection in 10/11 cases (1x fragmentation). 7 adenomata were removed as combined ESD/EMR. All intraoperative bleedings and microperforations were successfully managed endoscopically. However, in one patient a secondary perforation occurred three days after ESD with the need of surgery. A second patient with prior LG adenoma in biopsy was operated electively due focal pT1bG2R0 adenocarcinoma. Mortality was 0% in the group.

Conclusions:

Widespread ESD and ESD/EMR is feasible as surgery sparing resection in selected cases with widespread papillary and small intestinal adenomata.