Post written by Zaheer Nabi, MD, DNB, from the Asian Institute of Gastroenterology, Hyderabad, India.

In this study, the feasibility and safety of exposed versus nonexposed endoscopic full-thickness resection (EFTR) in patients with large (≥10 mm) duodenal subepithelial lesions were evaluated.

Exposed EFTR was performed using a conventional electrosurgical knife, and the ensuing full-thickness defect was closed with endoclips. Nonexposed or device-assisted EFTR was performed using a device designed for gastroduodenal-specific full-thickness resection (FTRD; Ovesco Endoscopy, Tübingen, Germany).

Endoscopic resection, particularly endoscopic submucosal dissection (ESD), is difficult to perform in the duodenum because of anatomical reasons and its thin muscular layer, which poses a high perforation risk. In addition, larger submucosal lesions (≥10 mm) commonly adhere to the muscular layer. In such instances, EFTR may be a viable treatment option.

However, there are limited data regarding the safety and efficacy of EFTR in duodenal subepithelial lesions, particularly neuroendocrine tumors measuring >1 cm in diameter. We analyzed the feasibility, safety, and efficacy of EFTR in patients with relatively large duodenal subepithelial lesions.

In 20 patients with duodenal subepithelial lesions, we compared the efficacy of exposed and nonexposed (device-assisted) EFTR. Pre-operative evaluation included imaging (EUS and Ga-DOTANOC positron emission tomography CT) and biopsy. The majority of lesions were well-differentiated neuroendocrine tumors averaging 14.2 mm in size. Exposed EFTR was successfully performed in all the cases.

In contrast, device-assisted EFTR was not possible in 2 instances, owing to the large size and location of the lesion, respectively. Three patients experienced adverse events, including leakage in 2 cases of exposed EFTR and partial lumen obstruction in 1 case of device-assisted EFTR. At a mean follow-up of approximately 1 year, there was no recurrence. 

In a subset of patients with large (>10 mm) duodenal subepithelial lesions, our findings suggest that EFTR may offer an alternative to surgery. However, caution is advised, particularly when performing an exposed EFTR, because of the possibility of adverse events such as delayed leaks. To evaluate the efficacy of EFTR in cases of duodenal neuroendocrine tumors, long-term follow-up studies are necessary.

Multiple endoscopic techniques for the treatment of duodenal subepithelial lesions have evolved. These include EMR, ligation or cap-assisted EMR, ESD, and endoscopic fibrotic resection. The selection of these techniques should be individualized based on the size and location of the lesion and the available expertise. EFTR has the potential to expand the indications for endoscopic resection in these lesions.

Technique of exposed or conventional endoscopic full-thickness resection. A, Large neuroendocrine tumor in the first part of the duodenum. B, Circumferential incision around the lesion. C, Endoscopic full-thickness resection after internal traction using a rubber band and 2 endoclips. D, Full-thickness defect after completion of full-thickness resection. E, Closure of the defect with loop and endoclips. F, Completion of the closure.

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