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Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 14, 2016; 22(2): 600-617
Published online Jan 14, 2016. doi: 10.3748/wjg.v22.i2.600
Approach to the endoscopic resection of duodenal lesions
Jonathan P Gaspar, Edward B Stelow, Andrew Y Wang
Jonathan P Gaspar, Andrew Y Wang, Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA 22908, United States
Edward B Stelow, Department of Pathology, University of Virginia, Charlottesville, VA 22908, United States
Author contributions: Gaspar JP wrote the manuscript; Stelow EB obtained and interpreted histopathology images; Wang AY critically revised the manuscript and provided the majority of the endoscopic images used in the figures.
Conflict-of-interest statement: The authors have no conflicts of interest, financial or otherwise, to report that are relevant to this manuscript. Dr. Wang discloses research funding from Cook Medical on the topic of metal biliary stents. Dr. Gaspar and Dr. Stelow have no disclosures to make with regard to this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Andrew Y Wang, MD, FACG, FASGE, Associate Professor, Co-Medical Director of Endoscopy, Division of Gastroenterology and Hepatology, University of Virginia Health System, Box 800708, Charlottesville, VA 22908, United States. ayw7d@virginia.edu
Telephone: +1-434-9241653 Fax: +1-434-2447590
Received: May 10, 2015
Peer-review started: May 12, 2015
First decision: September 11, 2015
Revised: October 14, 2015
Accepted: November 9, 2015
Article in press: November 9, 2015
Published online: January 14, 2016
Processing time: 241 Days and 11.7 Hours
Abstract

Duodenal polyps or lesions are uncommonly found on upper endoscopy. Duodenal lesions can be categorized as subepithelial or mucosally-based, and the type of lesion often dictates the work-up and possible therapeutic options. Subepithelial lesions that can arise in the duodenum include lipomas, gastrointestinal stromal tumors, and carcinoids. Endoscopic ultrasonography with fine needle aspiration is useful in the characterization and diagnosis of subepithelial lesions. Duodenal gastrointestinal stromal tumors and large or multifocal carcinoids are best managed by surgical resection. Brunner’s gland tumors, solitary Peutz-Jeghers polyps, and non-ampullary and ampullary adenomas are mucosally-based duodenal lesions, which can require removal and are typically amenable to endoscopic resection. Several anatomic characteristics of the duodenum make endoscopic resection of duodenal lesions challenging. However, advanced endoscopic techniques exist that enable the resection of large mucosally-based duodenal lesions. Endoscopic papillectomy is not without risk, but this procedure can effectively resect ampullary adenomas and allows patients to avoid surgery, which typically involves pancreaticoduodenectomy. Endoscopic mucosal resection and its variations (such as cap-assisted, cap-band-assisted, and underwater techniques) enable the safe and effective resection of most duodenal adenomas. Endoscopic submucosal dissection is possible but very difficult to safely perform in the duodenum.

Keywords: Duodenum; Polyp; Subepithelial; Lesion; Ampulla; Adenoma; Papillectomy; Endoscopic mucosal resection; Underwater; Endoscopic submucosal dissection

Core tip: Duodenal lesions can be categorized as subepithelial or mucosally-based. Endoscopic ultrasonography with fine-needle aspiration aides in the diagnosis of subepithelial lesions. Duodenal gastrointestinal stromal tumors and large or multifocal carcinoids are subepithelial lesions that should undergo surgical resection. Non-ampullary and ampullary adenomas and other mucosally-based duodenal lesions are amenable to endoscopic resection. Endoscopic papillectomy is effective at resecting ampullary adenomas but is not without risk. Various forms of endoscopic mucosal resection (cap-assisted, cap-band-assisted, and underwater) enable the resection of most duodenal adenomas. Endoscopic submucosal dissection is possible but very difficult to safely perform in the duodenum.