ASGE DDW Videos from Around the World | 2025-ENDOSCOPIC RESECTION OF CIRCUMFERENTIAL ADENOMA OF THE DUODENUM ASSOCIATED WITH PREEMPTIVE VACUUM THERAPY TO PREVENT LATE PERFORATION

Video Transcription

Circumferential lesions of the duodenum are uncommon, and due to their malignant potential, their resection is mandatory.  Mucosectomy of these lesions is a viable alternative to the Whipple procedure, a high-risk gastrointestinal  surgery, and can be performed safely and with good results in a single session. 51-year-old female patient with endoscopic and histological diagnosis of circumferential  adenoma of second portion of duodenum involving the major duodenal papilla. Endoscopic treatment was indicated after multidisciplinary discussion.  Piecemeal endoscopic mucosal resection was performed with subsequent cauterization the borders of the lesion.  Papillectomy and prophylactic pancreatic duct stent placement were also performed.  Due to the extensive resection area, an endoluminal vacuum therapy was used to prevent perforation.  First of all, it was performed an endoscopic papillectomy and placed a prophylactic 5 French pancreatic duct stent using a papillotome and guide wire.  Then, submucosal injections was administered with saline solution that raises a blister, allowing to decrease bleeding and to remove the tissue without demagging.  After that, we proceeded with the endoscopic mucosal resection using hot snare.  Here we can see how much remains to resect. So, we continued performing the submucosal injection and the EMR.  In the attempt to prevent bleeding, thermal coagulation was applied to the exposed vessel. Therefore, adequate hemostasis was achieved.  Due to the extensive resection area, an endoluminal vacuum therapy was used to prevent perforation.  The patient became asymptomatic after fasting, so oral feeding was introduced. She was discharged on the sixth day after endoscopic resection.  In the postoperative period the patient had abdominal discomfort after eating solid foods,  and a new endoscopy demonstrated duodenal stenosis requiring endoscopic balloon dilatation.  She underwent four EBD sessions with increased lumen diameter and symptomatic improvement. At six-month follow-up, there was no tumor recurrence.  Circumferential lesions of the duodenum can be safely treated with endoscopic therapy and with good results in a single session.  The preemptive EVT in the perioperative period and the sequential EBDs because of the luminal stenosis must be considered in therapeutic planning.

Video Summary

A 51-year-old woman underwent a successful endoscopic mucosal resection to remove a circumferential adenoma in the duodenum as an alternative to the high-risk Whipple procedure. The process involved piecemeal resection, papillectomy, and stent placement. Endoluminal vacuum therapy was employed to prevent perforation, aiding patient recovery. Postoperatively, she experienced duodenal stenosis, which required four balloon dilation sessions. Six months later, no tumor recurrence was observed. This case highlights that endoscopic treatment with adequate preemptive measures, such as EVT and EBD, can safely manage duodenal lesions in a single session while ensuring long-term effectiveness.

Asset Subtitle

Ada Alexandrina Brom dos Santos Soares

Keywords

endoscopic mucosal resection

duodenal adenoma

endoluminal vacuum therapy

balloon dilation

tumor recurrence