Endoscopic Resection of Complex Duodenal Polyps
By Klaus Mönkemüller, MD, PhD, FASGE (USA), FJGES (Japan)
Pedunculated Duodenal Adenoma, 0-Ip
This polyp is located in the second part of the duodenum.
What resection technique would you use?
And what precautions would you take to prevent the polyp from going “away” into the distal bowel?
When faced with a larger sessile or pedunculated polyp located in the distal duodenum the endoscopist should plan a complete (R0) resection, but actively anticipate a) what to do once the polyp is resected and b) how to deal with any potential complication (bleeding and perforation).
To prevent the polyp from migrating distally the following measures may be taken:
a) place the patient in decubitus supine position, or b) use anti-motility agent such as glucagon or Buscopan. In addition, both the endoscopist and the assistant should be ready. to catch the polyp with the snare once it is resected, or have a Roth´s net readily available. to quickly in and catch the polyp. One trick I like to use is always using a distal transparent cap on the scope to perform the resection, and then suction part of the polyp into the cap. and retrieve out (or at least into the stomach, so it does not move away in the duodenum).
In order to prevent complications during and after the endoscopic resection one can do the following:
a) Use submucosal injection (ideally with saline-epinephrine mix 1:100,000), which will raise the lesion, distantiate the neoplasia from the muscular propria, and decrease intraprocedural bleeding, allowing for a cleaner operating field.
b) Perform underwater resection, which allows for the neoplasm to float and thus, have less chances of transmitting electrosurgical current to the base (hence less perforation). Also, by using water, the electrosurgery currents applied with the snare are dissipated into the water, decreasing heating damage to the tissue.
c) Another great option for this pedunculated polyp is to use a prophylactic endoloop.
d) When I resect duodenal lesions, I always use clips to close the wound. The literature clearly shows that immediate and delayed bleeding is a very common complication of duodenal endoscopic resections. On some occasions, when the resection site is broad and large, I have also used hemostatic hydrogels (Purastat), especially in patients who have been or are on anticoagulation. Starting proton pump inhibitors at high dose for 2-3 days is also advisable (and keep the PPI for about one month to aid in healing).
e) Finally, when resecting a duodenal polyp always take into account its location to the papilla of Vater. First, to make sure it’s not an ampullary lesion, and second to plan the resection well, because in these scenarios, using a side-viewing endoscope may improve visibility and ensure a complete resection (R0).
f) Sometimes using argon plasma coagulation may be necessary to ablate remains of lesion or treat bleeding. Careful attention must be paid to the amount of argon plasma used, as too much distention or gas may result in pancreatitis (1).
References:
Weigt J, Zimmermann LC, Mönkemüller K, Malfertheiner P. Acute pancreatitis after argon plasma coagulation of duodenal polyps in a patient with familial adenomatous polyposis. Endoscopy. 2007 Feb;39 Suppl 1:E278. doi: 10.1055/s-2007-966664. Epub 2007 Oct 24. PMID: 17957607.
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Resection of duodenal lesions is recognized to be one of the highest risk endoscopic interventions that can be made.
I always consider the relationship to the major and minor papillae and the orientation to the greater sac and other extraluminal structures.
Then I assess the polyp itself and consider my choice of scope; a duodenoscope may improve visualization, and the elevator offers additional control over devices deployed.
Then I consider the potential benefit of water immersion vs CO2 insufflation.
Use of a lifting agent has benefits but in some instances water immersion is sufficient to complete a resection without lifting.
Growths such as that defined below are subject to peristaltic traction and become pedunculated; as with the colon, consideration for mitigating bleeding may include the use of epinephrine, loops, or clips as the stalk harbors an artery.
Generous use of an agent to mitigate motility is always required to help retain the resected lesion. Introduction of electrocautery may stimulate contractile activity.
Anticipate how the resected lesion will be removed and always be mindful of how the airway will be protected when the lesion is withdrawn through the pharynx.