Clinical Outcome of Endoscopic Resection for Nonampullary Duodenal Tumors

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1 The 9 th Nottingham Endoscopy Masterclass 9:50-10:10 Clinical Outcome of Endoscopic Resection for Nonampullary Duodenal Tumors Satoru Nonaka, MD, PhD Endoscopy Division National Cancer Center Hospital, Tokyo

2 Endoscopy Division, National Cancer Center Hospital Introduction Duodenal endoscopic resection (ER) is most difficult Narrow lumen Poor stability of the endoscope Brunner glands in submucosal layer Thin muscle layer Higher risk of complications Difficult access for emergency surgery

3 Endoscopy Division, National Cancer Center Hospital Duodenal Wall 1mm mm 0.5mm

4 Endoscopy Division, National Cancer Center Hospital Duodenal EMR: Injection & Cut SDA, sporadic adenoma, 12mm

5 Duodenal EMR: Injection & Cut Endoscopy Division, National Cancer Center Hospital

6 Endoscopy Division, National Cancer Center Hospital Duodenal EMR: Injection & Cut 0-IIa, 12mm, tubular adenoma, phmx, pvm0

7 Endoscopy Division, National Cancer Center Hospital Duodenal EMR: Strip Biopsy 0-IIa, 25mm, 2 nd part, opposite side of papilla

8 Duodenal EMR: Strip Biopsy Endoscopy Division, National Cancer Center Hospital

9 Endoscopy Division, National Cancer Center Hospital Duodenal EMR: Strip Biopsy 0-IIa, 25mm, Well differentiated adenocarcinoma M, ly(-), v(-), phmx, pvm0

10 Duodenal ESD Case Duodenal Cancer, 0-IIa, 25mm, 2 nd Part

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12 Duodenal ESD Case #1 #1 #2 #2 #3 #3 #4 #4 #5 #5 #6 #6 #7 #7 #8 #8#9 #9 #6 m 0-IIa, 25mm, Well differentiated adenocarcinoma, low grade atypia, M, ly(-), v(-), phm0, pvm0

13 Duodenal ESD case 2 nd part, 0-IIa, M, 24mm, tub1, ly(-), v(-), phm0, pvm0 Endoscopy Division, National Cancer Center Hospital

14 Duodenal EMR: 3 piece resection 2 nd part, 0-IIa, M, 20mm, tub1, ly(-), v(-), phmx, pvm0 Endoscopy Division, National Cancer Center Hospital

15 Prophylactic Clipping Case Duodenal Cancer, 24 22mm, M, ly(-), v(-), phm0, pvm0

16 Closure by loop snare with endo-clip 2 nd part, 0-IIa, 38mm, tub1, M, ly(-), v(-), phmx, pvm0 Endoscopy Division, National Cancer Center Hospital

17 Closure by loop snare with endo-clip Endoscopy Division, National Cancer Center Hospital

18 Perforation during ESD Subsequent Surgery

19 Delayed Perforation Case Emergency Surgery

20 EMR for Duodenal Adenoma of FAP Patient

21 Endoscopy Division, National Cancer Center Hospital Treatment Strategy in NCCH Adenocarcinoma (HGIN) Adenoma (LGIN) csm Depth cm >10mm Size 10mm Surgery HGIN; High-grade intraepithelial neoplasia LGIN; Low-grade intraepithelial neoplasia ER ER ER or follow up

22 Treatment Strategy in NCCH Our current position is to refrain from aggressively performing duodenal ESD. Nonaka S, et al. Endoscopy : Endoscopy Division, National Cancer Center Hospital

23 Author Year Case (no.) Tx Size (mm) Delayed bleeding (%) Perfora tion (%) Recurren ce (%) Period (M) Oka EMR Apel EMR Lepilliez EMR Alexander EMR Abbass EMR Fanning EMR 41/ Maruoka EMR Matsumoto ESD Jung ESD Inoue ER Hoteya ESD Nonaka ER Endoscopy Division, National Cancer Center Hospital

24 Endoscopy Division, National Cancer Center Hospital Patients and Methods < > Duodenal ERs 176 Patients 229 Lesions Duodenal adenoma/carcinoma 127 Patients 134 Lesions EMR: 118 Patients 125 Lesions ESD: 9 Patients 9 Lesions Excluded as follows: NET FAP Ampullary duodenal tumors EMR including Strip Biopsy & Polypectomy ESD including circumferential incision with snaring

25 Study Flow Diagram Nonampullary Duodenal Tumors 127 Patients 134 Lesions EMR 125 (Ca:72, Ad:53) ESD 9 (Ca:6, Ad:2) Intraoperative perforation 1 (Discontinuation of ESD) Piecemeal 42 (Ca:31, Ad:11) En-bloc 83 (Ca:41, Ad:42) Piecemeal 1 (Ca:1) En-bloc 7 (Ca:5, Ad:2) Local recurrence 1 (Re-EMR) Non-R0 37 (Ca:19, Ad:18) R0 46 (Ca:22, Ad:24) Non-R0 3 (Ca:2, Ad:1) R0 4 (Ca:3, Ad:1) Local recurrence 1 (Surgery) Delayed perforation 1 (Emergency surgery)

26 Complications Perforation, no. Intraoperative * Delayed ** Delayed Bleeding, no. 1 st part 2 nd part 3 rd part Anastomosis 3 (3%) 2 (2%) 1 (1%) 11 (9%) 0/24 (0%) 9/97 (9%) 2/10 (20%) 0/3 (0%) with Prophylactic Closure without Prophylactic Closure 7/117 (6%) 5/17 (29%) Blood Transfusion 1 (1%) * One patient underwent subsequent surgery ** Emergency surgery Endoscopy Division, National Cancer Center Hospital

27 Endoscopy Division, National Cancer Center Hospital Long-Term Outcomes 96 patients followed up more than one year Local Recurrence 2 (2%) Death by Duodenal Tumor 0 (0%) Death by Other causes 4 (4%) Follow-up Periods, months, median (range) 38 (12-181)

28 Endoscopy Division, National Cancer Center Hospital Technical Results of EMR/ESD Location, no. 1 st part 2 nd part 3 rd part Anastomosis EMR (125) ESD (9) 18 (15%) 94 (75%) 10 (8%) 3 (2%) 6 (67%) 3 (33%) 0 (0%) 0 (0%) Tumor Size*, mm (range) 20mm >20mm 12 (3-50) 109 (87%) 16 (13%) 14 (5-45) 5 (56%) 4 (44%) Procedure time*, min (range) 20 (5-190) 78 (20-246) *median

29 Endoscopy Division, National Cancer Center Hospital Technical Results of EMR/ESD Resection, no. En-bloc 20mm >20mm R0 Discontinuation EMR (125) ESD (9) 83 (66%) 78/109 (72%) 5/16 (31%) 46 (37%) 0 (0%) 7 (78%) 4/5 (80%) 3/4 (75%) 4 (44%) 1 (11%) Complications, no. Perforation Delayed Bleeding Histology *, no. Adenoma Intramucosal ca Submucosal ca 1 (1%) 11 (9%) 52 (42%) 70 (56%) 3 (2%) 2 (22%) 0 (0%) 2 (22%) 5 (56%) 1 (11%)

30 Discussion Balance of ESD <Benefits> En-bloc resection Accurate diagnosis Recurrence <Risks> Perforation, Bleeding, Longer procedure

31 Discussion <Injection Solutions> Saline Glyceol MucoUp Softer Shorter Intermediate Stiffer Longer EMR EMR & ESD ESD

32 CO 2 insufflation Discussion Prophylactic effect for perforation Reducing of abdominal fullness

33 Discussion Is prophylactic clipping effective? Effective for protection from exposure of bile & pancreatic juice

34 Endoscopy Division, National Cancer Center Hospital Summary En-bloc resection by ESD is ideal, but there is a big challenge on the technical difficulty and safety of ESD. Curability and safety of EMR is maintained and small lesion 20mm is controllable by EMR. Endoscopists must be particularly concerned about perforations including the possibility of delayed perforations. Duodenal ER is feasible as a therapeutic procedure, but it should only be performed by highly skilled endoscopists.

35 Endoscopy Division, National Cancer Center Hospital Opinion of NCCH The risks of performing an en-bloc resection by ESD are greater than the benefits of ESD in some cases. It is acceptable to perform a piecemeal resection by EMR for small lesions based on the excellent prognosis.

36 野中哲 Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan Thank you for your kind attention