Endoscopic management of non-ampullary duodenal adenomas

Duodenal polyps are found in 0.1 % to 0.8 % of all upper endoscopies. Duodenal adenomas account for 10 % to 20 % of these lesions. They can be sporadic or occur in the setting of a hereditary predisposition syndrome, mainly familial adenomatous polyposis. Endoscopy is the cornerstone of management of duodenal adenomas, allowing for diagnosis and treatment, primarily by endoscopic mucosal resection. The endoscopic treatment of duodenal adenomas has a high morbidity, reaching 15 % in a prospective study, consisting of bleeding and perforations, and should therefore be performed in expert centers. The local recurrence rate ranges from 9 % to 37 %, and is maximal for piecemeal resections of lesions > 20 mm. Surgical resection of the duodenum is flawed with major morbidity and considered a rescue procedure in cases of endoscopic treatment failures or severe endoscopic complications such as duodenal perforations. In this paper, we review the existing evidence on endoscopic diagnosis and treatment of non-ampullary duodenal adenomas.

P-P53 Textbook outcomes in pancreatoduodenectomy are improved in high volume specialist pancreas-only centres

Background Traditional single surgical quality indicators are commonly used however they are poor for assessing global outcomes for patients. Composite outcomes such as the ‘Textbook Outcome’ (TO) is a composite outcome to determine the success of the quality of the surgical process, and compare outcomes between institutions and patient groups, described by the Dutch Pancreatic Cancer Audit Group for Pancreatoduodenectomy (PD). They reported national TOs for PD of 58.3%, we compared this to TOs in a UK high volume specialist pancreas-only centre, Royal Stoke. Methods Patients who underwent PD from January 2017 to December 2020 were identified from our database. TO was defined as absence the following: post-operative pancreatic fistula (POPF) (grade B/C), post-pancreatectomy haemorrhage (PPH), bile leak, severe complications (Clavien Dindo grade III or more), 30-day readmission and 30-day mortality. Results 153 patients underwent PD during the 4-year study period. The median age was 71years (range 37-85 years), and there was a slight male preponderance (54.9%, 84/153). 47% had pancreatic ductal adenocarcinoma (72/153), 17% ampullary carcinoma (26/153), 9% cholangiocarcinoma (14/153), 9% duodenal carcinoma (14/153), and benign pathology included cases with IPMN and duodenal polyps with high grade dysplasia. There was a statistically significant difference in textbook outcome in our cohort compared to the Dutch Study (70.3%, 108/153 vs 58.3%, 895/1536; p=0.003086), with components of TO shown in Figure 1. Conclusions TO represent composite outcome for identifying good practice, areas for shared learning and areas for improvement. PD performed in high-volume pancreas-only specialist centers appear to have better outcomes following PD than lower-volume centres. Further investigation is required to assess why outcomes are different between centres, and identify how best practice can be shared.

A duodenal ampullary tumor with malignant transformation of papillary polyps: a case report and literature review

Periampullary carcinoma refers to a malignant tumor within 2 cm of the duodenal ampulla. Primary ampullary carcinoma is very rare, accounting for only 0.2% of malignant gastrointestinal tumors. The small intestine accounts for 75% of the length of the gastrointestinal tract, and primary tumors in the small intestine account for only 2% of all gastrointestinal tumors. Here, we report the case of a duodenal ampullary tumor with malignant transformation of parapapillary polyps. The patient had both a primary ampullary tumor and high-grade intraepithelial neoplasia of juxtapapillary adenomatous duodenal polyps.

Duodenal adenocarcinoma: a rare cause of intestinal obstruction in young adult

Primary adenocarcinoma of duodenum is a very rare and aggressive malignancy, found in middle or elderly age group and usually arising in the second portion of the duodenum, followed by third or fourth. Cancers of the first portion of the duodenum, especially the duodenal bulb are extremely rare. The causative factors for duodenal adenocarcinoma are dietary factors, ingestion of alcohol, coffee and use of tobacco. It may occur from duodenal polyps present in familial polyposis or may be associated. In young age it is associated with polyposis syndromes or with Crohn’s disease affecting small bowel. Very few reports discuss the diagnosis and treatment of such malignancy and very few cases have been reported in young age less than 30years. We are reporting a case of 22 years old gentleman who presented to us with history of recurrent abdominal pain and vomiting. After evaluation it was diagnosed as adenocarcinoma of third and fourth part of duodenum without any associated syndromes or inflammatory bowel diseases and was managed by surgical resection and chemotherapy.