Dr. Chahal is an expert in advanced endoscopy and interventional EUS. She's a program director of the Advanced Endoscopy Fellowship in the Department of Gastroenterology at Cleveland Clinic. She was the first endoscopist to perform the innovative procedures like EDGE, gallbladder drainage, gastrointestinalisomy at Cleveland Clinic, and many others. And she helps train her colleagues and fellows in these innovative procedures. So welcome, Dr. Chahal. Thank you so much. I would like to thank ASG and the course directors for giving me this opportunity. So the task at hand is talking about the risky business of endoscopic therapies for dudenal adenomas. These are my disclosures. So let's talk a little bit about dudenum. What makes it such a risky and hostile environment when it comes to polypectomy? Dudenum has several unique anatomic properties, which makes it most hazardous area for polypectomy. It is richly vascular, and not to mention, it has several second-order arterial blood supply, which makes it very prone to sudden and delayed bleeding. Whenever we are working in the dudenum, most of you must have encountered it's not easy to maintain a stable scope position, especially if you're working at the sweep or around the flexures. You're working in a very tight, narrow space. And when you're trying to push the scope down, you may either fall back in a short scope position, or you may be creating a loop in the stomach. So handling a scope in the dudenum, especially for a large polyp removal, is not easy. You may be dealing with several tools, including a side-viewing scope or a standard upper scope with cap. Further anatomic challenges when it comes to dudenum include thin submucosal layer and a very thin muscularis propria. Due to the thin submucosal layer, when you inject the submucosal injectate, it spreads very rapidly and it's very difficult to maintain that elevation. And as we see very commonly in our practice, I'm sure most of you must have encountered, you get a patient for polyp removal and somebody has already done multiple biopsy. Since it has a very thin submucosal layer, now you are dealing with the fibrosis at the time of polyp removal. Presence of thin muscularis propria makes it very easy for us to perforate, especially if you're using tools and techniques like ESD knife. And most of you must have encountered, I sure have, if you are using a very wide pronged clips, it's very easy to cause perforation when we are trying to deploy a hemo clip. Mortalities have been described from delayed perforation because of all these anatomic issues with the dudenum. Furthermore, dudenum has very extensive second-order blood vessels. Delayed bleeding has been reported in up to 40%. The risk of delayed bleeding goes as high as 40%, especially when we are taking large polyps out from the dudenum. And we are not talking about small oozing. We are talking about significant bleeding. Often patients are in the ICU required blood transfusions. Now to add to these challenges, dudenum is an organ where the resection bed gets exposed to digestive secretions like bile and pancreatic juices. Because of this, it is believed that the risk of adverse event, especially bleeding and perforation, is higher because of these highly alkaline digestive juices. Study from Inouye found that the delayed complications post-polypectomy in the dudenum distal to ampulla were higher because the resection bed get exposed to bile and pancreatic secretions. Now let's move on to the polyp management. There are two parts to polyp management. We are removing the polyp, and then you are equipping yourself to deal with the fallout that may happen, that is the delayed complication, and not just the immediate. There are no standardized techniques for polyp removal in the dudenum. Options are you go with a cold-snare polypectomy, you do standard hot-snare EMR, or hot-snare with a snare tip coagulation, and then finally ESD. Let's talk about each of them. So starting with the cold-snare, what is the data? I'm going to go over several studies. So this is the first study, it's a retrospective data which was published in GIE in 2022. 43 patients, more than one centimeter size dudenal polyp, mean size was 26.5 millimeters, so a large dudenal adenomas. Range of polyp size was 10 to 70 millimeter. With cold-snare polypectomy, when it came to complications like post-procedural bleeding and perforation, but the recurrence rate was high, noted to be 46%. Another recent study published in GIE, multicenter 127 non-ampullary polyps, all larger than one centimeter in size with a median size of 20 millimeter. Again, with cold-snare polypectomy, complications like immediate delayed bleeding and perforation were reasonably low, but the recurrent adenoma rate was high at 31%. And the recurrence was even higher if a large polyp more than 20 millimeter was removed with a recurrence again in 40s, 41% to be precise. Another prospective study published in GIE last year by Burke and his group compared cold-snare polypectomy with the traditional hot-snare EMR. They looked at 50 dodenal polyps in the cold-snare and compared that to 54 with a hot-snare EMR. Look at the data. With the intra-procedural bleeding, post-procedural bleeding was much less in the cold-snare and significantly higher in the hot-snare EMR. But perforation comparable, recurrence was significantly higher in the cold-snare compared to EMR. So what do we conclude from this? Cold-snare EMR, while it reduces the risk of adverse events like immediate and delayed bleeding and possibly perforation, it has a significantly high recurrence rate, especially when it comes to large dodenal polyps. Moving on to EMR, let's compare EMR with snare-tip coagulation and just a conventional EMR alone. This is a prospective single-center study which looked at 54 polyps taken out with EMR snare-tip coagulation, median polyp size was 30 millimeter, and they compared this to the historical cohort of 125 polyps with a median size same about 30 millimeter taken out with conventional EMR. The complications of intra-procedural bleeding and delayed bleeding were comparable in both groups, but patients who underwent EMR with snare-tip coagulation had significantly lower recurrence rate. With conventional EMR, the recurrence was 17%. Compared to the ones which had snare-tip, only 2%. So EMR, while associated with significantly high risk of complications like bleeding, immediate and delayed, if you add the snare-tip coagulation to it, it reduces the risk of recurrence to single digits. Moving on to ESD. For the dodenal ESD, the data I'm presenting here published in Endoscopy in 2022, it was a multi-center study, retrospective, 18 centers, huge cohort, over 3,000 patients, of these 1,000 underwent ESD for polyp removal, and over 2,000 had polyp removed by non-ESD methods, including EMR, underwater EMR, and cold snare polypectomy. The median lesion size was more than 10 millimeter, and the data showed, obviously with ESD, the procedure time was much longer. However, complications like intraprocedural perforation was significantly higher, not surprisingly, in the ESD group. Delayed bleeding, delayed perforation were comparable. The need for surgery to tackle the adverse events were higher in ESD group, but local recurrence was significantly lower in those who underwent ESD, compared to non-ESD methods like cold snare, hot snare, or underwater EMR. So, to conclude, ESD, it carries a very low recurrence rate, but despite the advances in tools and techniques, it still carries a high significant risk of adverse events, especially the perforation, and our center, we use it selectively for patients who have high-risk features for polyp, or if they have a high-grade dysplasia. So, moving on to how do we manage the fallout from the duodenal polyp removal, and does the closure reduces the risk of adverse events? So, what's the data on closure after duodenal ESD? This is a large retrospective study of 173 patients, where they did a complete closure in 67, incomplete in seven, and they did not close 26 of these patients. The mean lesion size, they were all large, measuring more than 30 millimeter. Notice the outcome. Patients who underwent complete closure has significantly lower delayed adverse events, especially bleeding and perforation, compared to those who had incomplete closure or no closure at all. What about closure after duodenal EMR? So, this is a retrospective study from Kashab and Group, multicenter study looking at 36 patients with a mean polyp size of more than 10 millimeter, mean size of 25 millimeter. They used the TTS suturing system. They were able to achieve complete closure in 78% of the patient, and they were able to use adjunctive tools like CLIPS in another 22. The risk of intraprocedural bleeding, the rate of intraprocedural bleeding and perforation was 24% and 5%, but there was no delayed bleeding or delayed perforation in this cohort. So, what is our approach? For smaller duodenal polyps, less than 10 millimeter, we use cold-snare polypectomy. For larger duodenal polyps, we use EMR with snare-tip coagulation. Close the defect if technically feasible. Otherwise, we use topical hemostatic agents. If the large polyp is removed more than 30 millimeter in size and we were not able to achieve the closure, we admit the patients for observation and we use ESG, as I mentioned earlier, in highly selective cases with high-risk features or with high-grade dysplasia. So, in summary, ladies and gentlemen, duodenum indeed is the most hazardous place in the GI tract for polypectomy. We should take great care and planning whenever we embark on polyp removal. Plan not only just for the polypectomy, but also how to manage the fallout. Cold-snare polypectomy is good for small polyps, but it has a prohibitively high risk of recurrence, especially for the large polyps. ESG, while it has a low recurrence rate, carries a high risk of adverse events like perforation. EMR with snare-tip coagulation carries promise and reduces the risk of recurrence in single digits. And whenever feasible, close the defects or use topical hemostatic agents. Thank you so much. And I would like to thank my colleague, Amit Bhat, for sharing the slides. Thank you.

duodenal adenomas

endoscopy techniques

polyp removal

complication management

Cleveland Clinic