Potential risk during endoscopic management of large duodenal polyps

Introduction: With steady advances in endoscopic techniques and devices over the past decades, endoscopic intervention has largely supplanted the common surgical approaches of the past. Endoscopic resection is now confidently and safely performed to manage large colon polyps, which historically were managed surgically, having a report of less than 5% recurrence. While there is a robust body of evidence on the endoscopic management of colonic polyps, data on outcomes of large duodenal polyps managed endoscopically are scarce. With an increasing number of esophagogastroduodenoscopies (EGDs), and depending on the clinical presentation, endoscopic features and histopathology, the rate of duodenal adenomas found incidentally increased, however, the pathogenesis characteristics of small intestinal adenomas and adenocarcinomas is not fully revealed. Duodenal polyps are found to be occurred sporadically, and belonging to familial adenomatosis polyposis (FAP) syndrome. It is postulated that the adenoma to carcinoma progression sequence of colorectal cancer is the same observed phenomenon in small bowel tumors. This study aimed to review the patient characteristics, EMR techniques, procedure outcomes, adverse events, and recurrence of large duodenal polyps. Materials and methods: Patients were included if they had pathologically confirmed non-ampullary duodenal polyps that were either sporadic or familial adenomatous polyposis syndrome-related and, had received EMR with at least one follow-up EGD for surveillance. Descriptive statistics were employed to report findings. Results: A total of 65 patients underwent a total of 90 EMRs for large duodenal polyps. The mean age was 65.4 years and including 29 female patients. Complete resection of the visible mass was achieved in 96.9% of cases. Intraprocedural hemostatic intervention was required in 18.5% of patients. Delayed bleeding was noted in 9%, and delayed perforation required surgical intervention in 2.2% of patients with no mortality. Surgical intervention after EMR was needed in 12.7%: in two patients for delayed perforation, in three for recurrence of high-grade dysplasia, and in one patient each for resection of a full-thickness lesion, resection of a carcinoid tumor near the pylorus, and resection of a difficult to access adenoma with a concurrent ampullary lesion. Eleven (16.9%) patients had recurrent duodenal polyps on follow-up EGD. Conclusion: The talented endoscopists are critically required for endoscopic management of large duodenal polyps. While most immediate adverse events can be managed endoscopically, all Preventive measures for delayed perforation should be applied before completing EMR as these usually require surgical intervention.