Abstract
Background and study aims Adenomas of the duodenum and ampulla are uncommon. For lesions ≤ 20 mm in size and
confined to the papillary mound, endoscopic resection is well supported by systematic
study. However, for large laterally spreading lesions of the duodenum or papilla (LSL-D/P),
surgery is often performed despite substantial associated morbidity and mortality.
We aimed to compare actual endoscopic outcomes of such lesions and costs with those
predicted for surgery using validated prediction tools.
Patients and methods Patients who underwent endoscopic resection of LSL-D/P were analyzed. Two surgeons
assigned the hypothetical surgical management. The National Surgical Quality Improvement
Program (NSQIP), and the Portsmouth Physiological and Operative Severity Score for
the enUmeration of Mortality and morbidity (P-POSSUM) were used to predict morbidity,
mortality, and length of hospital stay. Actual endoscopic and hypothetical surgical
outcomes and costs were compared.
Results A total of 102 lesions were evaluated (mean age of patients 69 years, 52 % male,
mean lesion size 40 mm). Complete endoscopic resection was achieved in 93.1 % at the
index procedure. Endoscopic adverse events occurred in 18.6 %. Recurrence at first
surveillance endoscopy was seen in 17.7 %. For patients with ≥ 2 surveillance endoscopies
(n = 55), 90 % were clear of disease and considered cured (median follow-up 27 months).
Compared with hypothetical surgical resection, endoscopic resection had less morbidity
(18 % vs. 31 %; P = 0.001) and shorter hospital stay (median 1 vs. 4.75 days; P < 0.001), and was less costly than surgery (mean $ 11 093 vs. $ 19 358; P < 0.001).
Conclusion In experienced centers, even extensive LSL-D/P can be managed endoscopically with
favorable morbidity and mortality profiles, and reduced costs, compared with surgery.
