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Endoscopic removal of a duodenal adenoma
201
It would seem that retained intestinal tubing should be
removed if this can be done with minimal risk and discomfort to the patient, particularly if there is a concurrent disorder which might prevent its passage. As demonstrated, the gastrointestinal endoscopist can use the biopsy forceps available with fiberoptic endoscopes. Other manipulating and grasping instruments probably can be easily constructed that would pass through the biopsy channel of available fiber endoscopes. These devices would increase the capability of endoscopic foreign body removal from the stomach. Robert L. Slaughter, M.D. Marvin B. Shapiro, M.D. Veterans Administration Hospital 700 South 19th Street Birmingham, Alabama 35233
Endoscopic removal of a duodenal adenoma Endoscopic removal by snare and cautery of colon polyps is now almost commonplace. Relatively rare is the opportunity to similarly remove a duodenal polyp by peroral endoscopy. A 52 year old woman was referred because of "a tumor in the duodenum." For several years she had complained of rather vague pain in the right flank. In the course of investigation by her family physician, upper gastrointestinal radiography revealed a lobulated 3 cm x 4 cm polypoid lesion in the third portion of the duodenum (Figure la). The patient described no symptoms suggesting obstruction, and she denied melena. She was obese and had mild diabetes. The Olympus GIF instrument entered the third portion of the duodenum with remarkable ease. The lesion was attached to the anterior wall and clearly did not obstruct the lumen (Figure 2). Although a pedicle was not seen, the mobility of the polyp indicated a rather narrow base of attachment. The surface was lobulated and granular, quite distinct from the adjacent duodenal mucosa. The visual impression was that of an adenoma, not a submucosal lesion. Multiple forceps biopsies were taken from the friable surface.
Figure 1. (a) A lobulated polypoid defect sits within the third portion ofthe duodenum (arrows); (b) radiograph after endoscopic removal of polypoid adenoma. VOLUME 19, NO.4, 1973
Figure 2. Duodenoscopic view ofpolypoid adenoma which was then snared and removed. Through the biopsy channel we then inserted a Teflon tube containing a fine wire snare (identical to that we have used with the colonoscope). Within the narrow confines of the duodenal lumen we encountered difficulty both in forming an adequate wire loop and in guiding it over the lesion. Eventually we succeeded in firmly snaring somewhat more than half the polyp. With applying cautery (Cameron Miller Coagulator Model 80-7910), a 2.5 cm fragment fell free. Then we had the problem of retrieving our prize. It was too large to pull back through the pylorus. Reluctantly we released it and reinserted the snare to have a go at the remnant. Finally we looped and cauterized a sizable portion of the remainder of the polyp; this 1 cm fragment was withdrawn with the snare. The base of the polyp was left in place. Bleeding was minimal. After sleeping off the effects of Valium, the patient awoke refreshed, ate comfortably, and was released from the hospital the following day. There was no melena. Despite vigorous attempts at saline catharsis, only small amounts of liquid stool were expelled, and the larger fragment which had been let loose was never recovered. Serial sections of the multiple forceps biopsies and of the 1 cm retrieved fragment revealed a papillary adenoma. Barium meal radiographs the day following endoscopy showed the faint outline of a 1.5 cm subtractive defect at the site of the polyp. (Figure 1b). Our plan is to repeat the duodenoscopy in 3 months, compare any growth at the polyp base, and snare any visible adenomatous tissue. If substantial regrowth is seen, the patient will be referred for segmental resection of the third portion of the duodenum. Experience with snare and cautery by peroral duodenoscopy is too meager to justify any conclusions as to the applicability of this technic. At this writing we feel restraint at attempting to snare broad-based, submucosal lesions. Although we have demonstrated the feasability of endoscopically removing adenomatous polyps, the retrieval of large fragments for histologic study is a disturbing problem. And the rate of regrowth or recurrence of duodenal adenomas remains to be seen. William S. Haubrich, M.D. R. B. Johnson, M.D. Parviz Foroozan, M.D. The Scripps Clinic & Research Foundation 476 Prospect Street La Jolla, California 92037
It would seem that retained intestinal tubing should be
removed if this can be done with minimal risk and discomfort to the patient, particularly if there is a concurrent disorder which might prevent its passage. As demonstrated, the gastrointestinal endoscopist can use the biopsy forceps available with fiberoptic endoscopes. Other manipulating and grasping instruments probably can be easily constructed that would pass through the biopsy channel of available fiber endoscopes. These devices would increase the capability of endoscopic foreign body removal from the stomach. Robert L. Slaughter, M.D. Marvin B. Shapiro, M.D. Veterans Administration Hospital 700 South 19th Street Birmingham, Alabama 35233
Endoscopic removal of a duodenal adenoma Endoscopic removal by snare and cautery of colon polyps is now almost commonplace. Relatively rare is the opportunity to similarly remove a duodenal polyp by peroral endoscopy. A 52 year old woman was referred because of "a tumor in the duodenum." For several years she had complained of rather vague pain in the right flank. In the course of investigation by her family physician, upper gastrointestinal radiography revealed a lobulated 3 cm x 4 cm polypoid lesion in the third portion of the duodenum (Figure la). The patient described no symptoms suggesting obstruction, and she denied melena. She was obese and had mild diabetes. The Olympus GIF instrument entered the third portion of the duodenum with remarkable ease. The lesion was attached to the anterior wall and clearly did not obstruct the lumen (Figure 2). Although a pedicle was not seen, the mobility of the polyp indicated a rather narrow base of attachment. The surface was lobulated and granular, quite distinct from the adjacent duodenal mucosa. The visual impression was that of an adenoma, not a submucosal lesion. Multiple forceps biopsies were taken from the friable surface.
Figure 1. (a) A lobulated polypoid defect sits within the third portion ofthe duodenum (arrows); (b) radiograph after endoscopic removal of polypoid adenoma. VOLUME 19, NO.4, 1973
Figure 2. Duodenoscopic view ofpolypoid adenoma which was then snared and removed. Through the biopsy channel we then inserted a Teflon tube containing a fine wire snare (identical to that we have used with the colonoscope). Within the narrow confines of the duodenal lumen we encountered difficulty both in forming an adequate wire loop and in guiding it over the lesion. Eventually we succeeded in firmly snaring somewhat more than half the polyp. With applying cautery (Cameron Miller Coagulator Model 80-7910), a 2.5 cm fragment fell free. Then we had the problem of retrieving our prize. It was too large to pull back through the pylorus. Reluctantly we released it and reinserted the snare to have a go at the remnant. Finally we looped and cauterized a sizable portion of the remainder of the polyp; this 1 cm fragment was withdrawn with the snare. The base of the polyp was left in place. Bleeding was minimal. After sleeping off the effects of Valium, the patient awoke refreshed, ate comfortably, and was released from the hospital the following day. There was no melena. Despite vigorous attempts at saline catharsis, only small amounts of liquid stool were expelled, and the larger fragment which had been let loose was never recovered. Serial sections of the multiple forceps biopsies and of the 1 cm retrieved fragment revealed a papillary adenoma. Barium meal radiographs the day following endoscopy showed the faint outline of a 1.5 cm subtractive defect at the site of the polyp. (Figure 1b). Our plan is to repeat the duodenoscopy in 3 months, compare any growth at the polyp base, and snare any visible adenomatous tissue. If substantial regrowth is seen, the patient will be referred for segmental resection of the third portion of the duodenum. Experience with snare and cautery by peroral duodenoscopy is too meager to justify any conclusions as to the applicability of this technic. At this writing we feel restraint at attempting to snare broad-based, submucosal lesions. Although we have demonstrated the feasability of endoscopically removing adenomatous polyps, the retrieval of large fragments for histologic study is a disturbing problem. And the rate of regrowth or recurrence of duodenal adenomas remains to be seen. William S. Haubrich, M.D. R. B. Johnson, M.D. Parviz Foroozan, M.D. The Scripps Clinic & Research Foundation 476 Prospect Street La Jolla, California 92037