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Approach to benign duodenal polyps
Perspectives
PERSPECTIVES Approach to benign duodenal polyps Benign duodenal polyps are not often seen by gastroenterologists. Because of their relative rarity, there is no set of rules that can be followed when duodenal polyps are encountered. Several members of the International Editorial Board were requested to respond to a questionnaire about their personal approach to duodenal polyps. Their answers follow: How do you treat duodenal polyps? Barkun: Any pedunculated lesion is removed by using a snare. Whether the lesion is sessile or pedunculated, I will sometimes use the hot biopsy forceps if it very small. As a rule I do not use prior saline solution injection unless there is a very large sessile polyp. Small single sessile polyps or multiple small polyps are removed with the argon plasma coagulator. Endoscopic US is helpful in any sessile lesion where invasion is suspected. Goh: Single or small tumors are removed with the hot biopsy forceps, the argon plasma coagulator, or both. If tumors are small but multiple, I use the argon plasma coagulator to burn them off. I inject saline solution and use a snare to remove large flat polyps. When lesions are difficult to access, I prefer using the side-viewing duodenoscope. Novis: If tumors are small and less than 1 cm, I use regular snare polypectomy without saline solution. I never use the hot biopsy forceps, nor do I burn the polyps or their base with the argon plasma coagulator. If polyps are tiny (less than 2 mm), then I would use regular biopsy forceps only. Big flat polyps are removed after EUS to rule out malignancy; removal is accomplished with the injection of epinephrine and saline solution with piecemeal snare polypectomy. In the almost circumferential villous adenomas when surgery is contraindicated, the argon plasma coagulator can be used effectively. Ogoshi: I only remove duodenal polyps with a high risk for hemorrhage or stricture. Whether tumors are single or multiple, I use a mucosal resection technique with saline solution and a 2-channel instrument. I never use the hot biopsy forceps because of the risk of bleeding. Large flat polyps (approximately 3 cm in diameter) are removed by piecemeal polypectomy. Shim: If tumors are small and either single or multiple, I usually use the hot biopsy without saline solution injection. If they are larger than 0.5 cm, I use a transparent cap and saline solution injection 962
GASTROINTESTINAL ENDOSCOPY
with a 2-channel endoscope because this fixes the duodenal lesion enface in front of the endoscope. It is easy to snare duodenal lesions with a cap and control bleeding if it occurs. If, on the other hand, the lesion has high-grade dysplasia, I complete the polypectomy by using the argon plasma coagulator. Large polyps, approximately 3 cm in diameter, are removed with endoscopic mucosal resection by using a cap with a large amount of saline solution. The base is then fulgurated with the argon plasma coagulator. Tanaka: If the lesions are single and multiple (less than 1 cm), I use snare polypectomy after submucosal saline solution injection. I do not remove Brunner gland hyperplasia, but I do remove carcinoids by this technique. A large polyp is removed by laparoscopy or open surgery only when they are symptomatic. I never do endoscopic resection of large polyps. Do you endoscopically remove polyps at the ampulla of Vater? Barkun: I remove polyps from the ampulla of Vater after an ERCP with papillotomy to better identify landmarks. If the polyp is intimately associated with either biliary or pancreatic openings, I place a stent in the affected duct prophylactically for a few weeks after polypectomy. If there are any suspicious areas I would carry out EUS before polypectomy. I may use the argon plasma coagulator to ensure complete polypectomy. Goh: I usually remove these polyps in piecemeal fashion over a few sessions. I try to identify the ampulla and avoid resecting close to the papillary orifice although on some occasions I have transected the papilla with no adverse effects. I do not place a stent in the pancreatic or common duct prophylactically after procedure, having had no complications. Novis: I tend to refer patients with polyps of the ampulla of Vater that are larger than 1 cm for surgical resection. If the lesion is small I will try to remove it without taking the entire ampulla and remove the polyp over a few sessions. If there are only small fronds of polypoid tissue I remove them with biopsy forceps/small snare and treat the residual with a bicap. On rare occasions a large polyp was removed along with the ampulla of Vater. In this circumstance, the common duct would be cannulated afterward and the pancreatic duct if necessary. Shim: I have only a little experience with endoscopic ampullectomy for ampulla of Vater lesions. I usually recommend surgical ampullectomy or pancreaticoduodenectomy in ampullary lesions. I believe that preprocedural EUS is an important adjunct in evaluating lesions for endoscopic ampullectomy. In 3 cases I have used conventional polypectomy snare. After total ampullectomy, I inserted a stent in only one patient. VOLUME 55, NO. 7, 2002
Perspectives
Tanaka: I do not endoscopically remove polyps at the ampulla. Small benign tumors do not have to be removed, and large tumors may be malignant in their deeper portions even if superficial biopsy specimens are benign. We prefer “wide ampullectomy” by open surgery. Ogoshi: I have never seen a tumor of the ampulla of Vater that could be removed endoscopically. However, if it is to be accomplished, I would suggest stent placement in the pancreatic duct to prevent acute pancreatitis when the ampulla has been removed with the snare. Comment. It is evident that the approach to both large and small benign duodenal tumors does not follow any specific guideline, whether or not the polyp involves the ampulla. In general, all respondents tend to agree that the criteria for surgery would include the following: a large polyp (1-3 cm in size), a polyp in which EUS shows deeper tumor infiltration than is suspected, any polyp with severe dysplasia or carcinomatous infiltration, or significant recurrence of the polyp after apparently complete endoscopic removal. Jerome D. Waye, MD New York Alan Barkun, MD Montreal Khean-Lee Goh, MD Kuala Lampur Ben Novis, MD Tel-Aviv Kazuei Ogoshi, MD Niigata Chan-Sup Shim, MD Seoul Masao Tanaka, MD Fukuoka doi:10.1067/mge.2002.122035
VOLUME 55, NO. 7, 2002
GASTROINTESTINAL ENDOSCOPY
963
PERSPECTIVES Approach to benign duodenal polyps Benign duodenal polyps are not often seen by gastroenterologists. Because of their relative rarity, there is no set of rules that can be followed when duodenal polyps are encountered. Several members of the International Editorial Board were requested to respond to a questionnaire about their personal approach to duodenal polyps. Their answers follow: How do you treat duodenal polyps? Barkun: Any pedunculated lesion is removed by using a snare. Whether the lesion is sessile or pedunculated, I will sometimes use the hot biopsy forceps if it very small. As a rule I do not use prior saline solution injection unless there is a very large sessile polyp. Small single sessile polyps or multiple small polyps are removed with the argon plasma coagulator. Endoscopic US is helpful in any sessile lesion where invasion is suspected. Goh: Single or small tumors are removed with the hot biopsy forceps, the argon plasma coagulator, or both. If tumors are small but multiple, I use the argon plasma coagulator to burn them off. I inject saline solution and use a snare to remove large flat polyps. When lesions are difficult to access, I prefer using the side-viewing duodenoscope. Novis: If tumors are small and less than 1 cm, I use regular snare polypectomy without saline solution. I never use the hot biopsy forceps, nor do I burn the polyps or their base with the argon plasma coagulator. If polyps are tiny (less than 2 mm), then I would use regular biopsy forceps only. Big flat polyps are removed after EUS to rule out malignancy; removal is accomplished with the injection of epinephrine and saline solution with piecemeal snare polypectomy. In the almost circumferential villous adenomas when surgery is contraindicated, the argon plasma coagulator can be used effectively. Ogoshi: I only remove duodenal polyps with a high risk for hemorrhage or stricture. Whether tumors are single or multiple, I use a mucosal resection technique with saline solution and a 2-channel instrument. I never use the hot biopsy forceps because of the risk of bleeding. Large flat polyps (approximately 3 cm in diameter) are removed by piecemeal polypectomy. Shim: If tumors are small and either single or multiple, I usually use the hot biopsy without saline solution injection. If they are larger than 0.5 cm, I use a transparent cap and saline solution injection 962
GASTROINTESTINAL ENDOSCOPY
with a 2-channel endoscope because this fixes the duodenal lesion enface in front of the endoscope. It is easy to snare duodenal lesions with a cap and control bleeding if it occurs. If, on the other hand, the lesion has high-grade dysplasia, I complete the polypectomy by using the argon plasma coagulator. Large polyps, approximately 3 cm in diameter, are removed with endoscopic mucosal resection by using a cap with a large amount of saline solution. The base is then fulgurated with the argon plasma coagulator. Tanaka: If the lesions are single and multiple (less than 1 cm), I use snare polypectomy after submucosal saline solution injection. I do not remove Brunner gland hyperplasia, but I do remove carcinoids by this technique. A large polyp is removed by laparoscopy or open surgery only when they are symptomatic. I never do endoscopic resection of large polyps. Do you endoscopically remove polyps at the ampulla of Vater? Barkun: I remove polyps from the ampulla of Vater after an ERCP with papillotomy to better identify landmarks. If the polyp is intimately associated with either biliary or pancreatic openings, I place a stent in the affected duct prophylactically for a few weeks after polypectomy. If there are any suspicious areas I would carry out EUS before polypectomy. I may use the argon plasma coagulator to ensure complete polypectomy. Goh: I usually remove these polyps in piecemeal fashion over a few sessions. I try to identify the ampulla and avoid resecting close to the papillary orifice although on some occasions I have transected the papilla with no adverse effects. I do not place a stent in the pancreatic or common duct prophylactically after procedure, having had no complications. Novis: I tend to refer patients with polyps of the ampulla of Vater that are larger than 1 cm for surgical resection. If the lesion is small I will try to remove it without taking the entire ampulla and remove the polyp over a few sessions. If there are only small fronds of polypoid tissue I remove them with biopsy forceps/small snare and treat the residual with a bicap. On rare occasions a large polyp was removed along with the ampulla of Vater. In this circumstance, the common duct would be cannulated afterward and the pancreatic duct if necessary. Shim: I have only a little experience with endoscopic ampullectomy for ampulla of Vater lesions. I usually recommend surgical ampullectomy or pancreaticoduodenectomy in ampullary lesions. I believe that preprocedural EUS is an important adjunct in evaluating lesions for endoscopic ampullectomy. In 3 cases I have used conventional polypectomy snare. After total ampullectomy, I inserted a stent in only one patient. VOLUME 55, NO. 7, 2002
Perspectives
Tanaka: I do not endoscopically remove polyps at the ampulla. Small benign tumors do not have to be removed, and large tumors may be malignant in their deeper portions even if superficial biopsy specimens are benign. We prefer “wide ampullectomy” by open surgery. Ogoshi: I have never seen a tumor of the ampulla of Vater that could be removed endoscopically. However, if it is to be accomplished, I would suggest stent placement in the pancreatic duct to prevent acute pancreatitis when the ampulla has been removed with the snare. Comment. It is evident that the approach to both large and small benign duodenal tumors does not follow any specific guideline, whether or not the polyp involves the ampulla. In general, all respondents tend to agree that the criteria for surgery would include the following: a large polyp (1-3 cm in size), a polyp in which EUS shows deeper tumor infiltration than is suspected, any polyp with severe dysplasia or carcinomatous infiltration, or significant recurrence of the polyp after apparently complete endoscopic removal. Jerome D. Waye, MD New York Alan Barkun, MD Montreal Khean-Lee Goh, MD Kuala Lampur Ben Novis, MD Tel-Aviv Kazuei Ogoshi, MD Niigata Chan-Sup Shim, MD Seoul Masao Tanaka, MD Fukuoka doi:10.1067/mge.2002.122035
VOLUME 55, NO. 7, 2002
GASTROINTESTINAL ENDOSCOPY
963