Surgical Endoscopy

, Volume 32, Issue 6, pp 2859–2869 | Cite as

Endoscopic and surgical management of nonampullary duodenal neoplasms

  • Michael J. Bartel
  • Ruchir Puri
  • Bhaumik Brahmbhatt
  • Wei-Chung Chen
  • Daniel Kim
  • Carlos Roberto Simons-Linares
  • John A. Stauffer
  • Mauricia A. Buchanan
  • Steven P. Bowers
  • Timothy A. Woodward
  • Michael B. Wallace
  • Massimo Raimondo
  • Horacio J. Asbun



Sporadic nonampullary duodenal neoplasms (SNADN) can have malignant potential for which endoscopic and surgical resections are offered. We report combined gastroenterologic and surgical experience for treatment of SNADN, including endoscopic mucosal resection (EMR) and pancreas-preserving partial duodenectomy (PPPD).


We retrospectively reviewed 121 consecutive patients, who underwent 30 PPPDs and 91 EMRs for mucosal and submucosal SNADN. Decision to undergo EMR or surgical resection was based on expert endoscopist and surgeon discretion including multidisciplinary tumor board review. Main outcomes were recurrence rate of neoplasia and adverse events requiring hospital admission or prolonged care. EMRs were performed with submucosal lifting followed by snare resection. PPPD included total duodenectomy, supra-ampullary PPPD for neoplasms proximal to the ampulla, and infra-ampullary PPPD for lesions distal to the ampulla. Follow-up data were available for 65% of EMR and 73% of surgical patients.


Surgically resected neoplasia was larger with more advanced neoplasia and submucosal lesions. En bloc resection was achieved in all surgical resections and in 53% of EMRs. Post-EMR, mucosal and submucosal neoplasia recurred in 32 and 0%, respectively, including five neoplasms (26%) after an initial negative esophagogastroduodenoscopy. All recurrences were treated endoscopically. Complications occurred in 14 endoscopically and eight surgically treated patients, none requiring surgical intervention.


Post-EMR patients had higher recurrence of mucosal neoplasia, whereas submucosal neoplasms, mainly carcinoid, did not recur. Polyp size and positive resection margin were not associated with neoplasia recurrence. Patients with SNADN could benefit from a multidisciplinary approach to stratify the optimal treatment based on local expertise.


Nonampullary duodenal neoplasms Endoscopic resection Surgical resection 



Argon plasma coagulation


American Society of Anesthesiologists




Endoscopic mucosal resection


Endoscopic submucosal dissection


Endoscopic ultrasound


Pancreas-preserving duodenectomy


Pancreas-preserving partial duodenectomy


Pancreas-preserving total duodenectomy


Sporadic nonampullary duodenal neoplasms


Author contributions

MJB and RP contributed to the collection, analysis, and interpretation of data; drafting and critical revision of the article; and generation of the figures. BB, WCC, DK, and CRSL contributed to the collection of data and critical revision of the article. MAB contributed to the analysis and interpretation of data and critical revision of the article. JAS, SPB, TAW, MBW, MR, and AJH contributed to the conception and design, experiments, and critical revision of the article. All authors approved the final draft of the article.

Compliance with ethical standards


Dr. Wallace has research grants from Olympus, NinePoint, Boston Scientific, Cosmo Pharmaceuticals, and equity in iLumen. None of these disclosures were relevant for any part of this manuscript. Drs. Michael J. Bartel, Ruchir Puri, Bhaumik Brahmbhatt, Wei-Chung Chen, Daniel Kim, Roberto C. Simons Linares, John A. Stauffer, Mauricia A. Buchanan, Steven P. Bowers, Timothy A. Woodward, Massimo Raimondo, and Horacio J. Asbun have no conflicts of interest or financial ties to disclose.


  1. 1.
    Jepsen JM, Persson M, Jakobsen NO, Christiansen T, Skoubo-Kristensen E, Funch-Jensen P, Kruse A, Thommesen P (1994) Prospective study of prevalence and endoscopic and histopathologic characteristics of duodenal polyps in patients submitted to upper endoscopy. Scand J Gastroenterol 29:483–487CrossRefPubMedGoogle Scholar
  2. 2.
    Hochter W, Weingart J, Seib HJ, Ottenjann R (1984) Duodenal polyps. Incidence, histologic substrate and significance. Deutsche medizinische Wochenschrift 109:1183–1186CrossRefPubMedGoogle Scholar
  3. 3.
    Jung SH, Chung WC, Kim EJ, Kim SH, Paik CN, Lee BI, Cho YS, Lee KM (2010) Evaluation of non-ampullary duodenal polyps: comparison of non-neoplastic and neoplastic lesions. World J Gastroenterol 16:5474–5480CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Okada K, Fujisaki J, Kasuga A, Omae M, Kubota M, Hirasawa T, Ishiyama A, Inamori M, Chino A, Yamamoto Y, Tsuchida T, Nakajima A, Hoshino E, Igarashi M (2011) Sporadic nonampullary duodenal adenoma in the natural history of duodenal cancer: a study of follow-up surveillance. Am J Gastroenterol 106:357–364CrossRefPubMedGoogle Scholar
  5. 5.
    Oka S, Tanaka S, Nagata S, Hiyama T, Ito M, Kitadai Y, Yoshihara M, Haruma K, Chayama K (2003) Clinicopathologic features and endoscopic resection of early primary nonampullary duodenal carcinoma. J Clin Gastroenterol 37:381–386CrossRefPubMedGoogle Scholar
  6. 6.
    Kim GH, Kim JI, Jeon SW, Moon JS, Chung IK, Jee SR, Kim HU, Seo GS, Baik GH, Lee YC, Upper Gastrointestinal R Korean College of H. (2014) Endoscopic resection for duodenal carcinoid tumors: a multicenter, retrospective study. J Gastroenterol Hepatol 29:318–324CrossRefPubMedGoogle Scholar
  7. 7.
    Honda T, Yamamoto H, Osawa H, Yoshizawa M, Nakano H, Sunada K, Hanatsuka K, Sugano K (2009) Endoscopic submucosal dissection for superficial duodenal neoplasms. Dig Endosc 21:270–274CrossRefPubMedGoogle Scholar
  8. 8.
    Hoteya S, Yahagi N, Iizuka T, Kikuchi D, Mitani T, Matsui A, Ogawa O, Yamashita S, Furuhata T, Yamada A, Kimura R, Nomura K, Kuribayashi Y, Kaise M (2013) Endoscopic submucosal dissection for nonampullary large superficial adenocarcinoma/adenoma of the duodenum: feasibility and long-term outcomes. Endosc Int Open 1:2–7CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Endo M, Abiko Y, Oana S, Kudara N, Chiba T, Suzuki K, Koizuka H, Uesugi N, Sugai T (2010) Usefulness of endoscopic treatment for duodenal adenoma. Dig Endosc 22:360–365CrossRefPubMedGoogle Scholar
  10. 10.
    Sohn JW, Jeon SW, Cho CM, Jung MK, Kim SK, Lee DS, Son HS, Chung IK (2010) Endoscopic resection of duodenal neoplasms: a single-center study. Surg Endosc 24:3195–3200CrossRefPubMedGoogle Scholar
  11. 11.
    Lepilliez V, Chemaly M, Ponchon T, Napoleon B, Saurin JC (2008) Endoscopic resection of sporadic duodenal adenomas: an efficient technique with a substantial risk of delayed bleeding. Endoscopy 40:806–810CrossRefPubMedGoogle Scholar
  12. 12.
    Kim HK, Chung WC, Lee BI, Cho YS (2010) Efficacy and long-term outcome of endoscopic treatment of sporadic nonampullary duodenal adenoma. Gut Liver 4:373–377CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Kedia P, Brensinger C, Ginsberg G (2010) Endoscopic predictors of successful endoluminal eradication in sporadic duodenal adenomas and its acute complications. Gastrointest Endosc 72:1297–1301CrossRefPubMedGoogle Scholar
  14. 14.
    Alexander S, Bourke MJ, Williams SJ, Bailey A, Co J (2009) EMR of large, sessile, sporadic nonampullary duodenal adenomas: technical aspects and long-term outcome (with videos). Gastrointest Endosc 69:66–73CrossRefPubMedGoogle Scholar
  15. 15.
    Yamamoto Y, Yoshizawa N, Tomida H, Fujisaki J, Igarashi M (2014) Therapeutic outcomes of endoscopic resection for superficial non-ampullary duodenal tumor. Dig Endosc 26(Suppl 2):50–56CrossRefPubMedGoogle Scholar
  16. 16.
    Abbass R, Rigaux J, Al-Kawas FH (2010) Nonampullary duodenal polyps: characteristics and endoscopic management. Gastrointest Endosc 71:754–759CrossRefPubMedGoogle Scholar
  17. 17.
    Basford PJ, George R, Nixon E, Chaudhuri T, Mead R, Bhandari P (2014) Endoscopic resection of sporadic duodenal adenomas: comparison of endoscopic mucosal resection (EMR) with hybrid endoscopic submucosal dissection (ESD) techniques and the risks of late delayed bleeding. Surg Endosc 28:1594–1600CrossRefPubMedGoogle Scholar
  18. 18.
    Fanning SB, Bourke MJ, Williams SJ, Chung A, Kariyawasam VC (2012) Giant laterally spreading tumors of the duodenum: endoscopic resection outcomes, limitations, and caveats. Gastrointest Endosc 75:805–812CrossRefPubMedGoogle Scholar
  19. 19.
    Min YW, Min BH, Kim ER, Lee JH, Rhee PL, Rhee JC, Kim JJ (2013) Efficacy and safety of endoscopic treatment for nonampullary sporadic duodenal adenomas. Dig Dis Sci 58:2926–2932CrossRefPubMedGoogle Scholar
  20. 20.
    Navaneethan U, Lourdusamy D, Mehta D, Lourdusamy V, Venkatesh PG, Sanaka MR (2014) Endoscopic resection of large sporadic non-ampullary duodenal polyps: efficacy and long-term recurrence. Surg Endosc 28:2616–2622CrossRefPubMedGoogle Scholar
  21. 21.
    Nonaka S, Oda I, Tada K, Mori G, Sato Y, Abe S, Suzuki H, Yoshinaga S, Nakajima T, Matsuda T, Taniguchi H, Saito Y, Maetani I (2015) Clinical outcome of endoscopic resection for nonampullary duodenal tumors. Endoscopy 47:129–135CrossRefPubMedGoogle Scholar
  22. 22.
    Seo JY, Hong SJ, Han JP, Jang HY, Myung YS, Kim C, Lee YN, Ko BM (2014) Usefulness and safety of endoscopic treatment for nonampullary duodenal adenoma and adenocarcinoma. J Gastroenterol Hepatol 29:1692–1698CrossRefPubMedGoogle Scholar
  23. 23.
    Standards of Practice C, Adler DG, Qureshi W, Davila R, Gan SI, Lichtenstein D, Rajan E, Shen B, Zuckerman MJ, Fanelli RD, Van Guilder T, Baron TH (2006) The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc 64:849–854CrossRefGoogle Scholar
  24. 24.
    Gaspar JP, Stelow EB, Wang AY (2016) Approach to the endoscopic resection of duodenal lesions. World J Gastroenterol 22:600–617CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Poves I, Burdio F, Alonso S, Seoane A, Grande L (2011) Laparoscopic pancreas-sparing subtotal duodenectomy. JOP 12:62–65PubMedGoogle Scholar
  26. 26.
    Klein A, Nayyar D, Bahin FF, Qi Z, Lee E, Williams SJ, Byth K, Bourke MJ (2016) Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes. Gastrointest Endosc 84:688–696CrossRefPubMedGoogle Scholar
  27. 27.
    Moss A, Williams SJ, Hourigan LF, Brown G, Tam W, Singh R, Zanati S, Burgess NG, Sonson R, Byth K, Bourke MJ (2015) Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut 64:57–65CrossRefPubMedGoogle Scholar
  28. 28.
    Yamamoto H, Miura Y (2014) Duodenal ESD: conquering difficulties. Gastrointest Endosc Clin N Am 24:235–244CrossRefPubMedGoogle Scholar
  29. 29.
    Committee ASoP, Chathadi KV, Khashab MA, Acosta RD, Chandrasekhara V, Eloubeidi MA, Faulx AL, Fonkalsrud L, Lightdale JR, Salztman JR, Shaukat A, Wang A, Cash BD, DeWitt JM (2015) The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc 82:773–781CrossRefGoogle Scholar
  30. 30.
    Vallance S (1990) Duodenectomy without pancreatectomy for extensive benign villous adenoma of the duodenum. Aust Nz J Surg 60:311–314CrossRefGoogle Scholar
  31. 31.
    Marcello PW, Asbun HJ, Veidenheimer MC, Rossi RL, Roberts PL, Fine SN, Coller JA, Murray JJ, Schoetz DJ Jr (1996) Gastroduodenal polyps in familial adenomatous polyposis. Surg Endosc 10:418–421CrossRefPubMedGoogle Scholar
  32. 32.
    Stauffer JA, Raimondo M, Woodward TA, Goldberg RF, Bowers SP, Asbun HJ (2013) Laparoscopic partial sleeve duodenectomy (PSD) for nonampullary duodenal neoplasms: avoiding a whipple by separating the duodenum from the pancreatic head. Pancreas 42:461–466CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018
Corrected publication February/2018

Authors and Affiliations

  • Michael J. Bartel
    • 1
    • 2
  • Ruchir Puri
    • 3
  • Bhaumik Brahmbhatt
    • 1
  • Wei-Chung Chen
    • 1
  • Daniel Kim
    • 4
  • Carlos Roberto Simons-Linares
    • 1
  • John A. Stauffer
    • 4
  • Mauricia A. Buchanan
    • 3
  • Steven P. Bowers
    • 4
  • Timothy A. Woodward
    • 1
  • Michael B. Wallace
    • 1
  • Massimo Raimondo
    • 1
  • Horacio J. Asbun
    • 4
  1. 1.Department of GastroenterologyMayo ClinicJacksonvilleUSA
  2. 2.Section of GastroenterologyFox Chase Cancer CenterPhiladelphiaUSA
  3. 3.Department of SurgeryUniversity of FloridaJacksonvilleUSA
  4. 4.Department of SurgeryMayo ClinicJacksonvilleUSA

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