Description

Nonampullary duodenal polyps are found in up to 5% of all upper endoscopies; the vast majority are identified incidentally in asymptomatic patients. Although most are benign, adenomas are estimated to account for 10%–20% of these lesions. Most international guidelines recommend that all duodenal adenomas should be considered for endoscopic resection; this may be associated with a near 15% adverse event rate (predominantly bleeding and perforation) in prospective studies, with substantial local recurrence on surveillance. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review was to describe how individuals should be evaluated and risk-stratified for duodenal polyps, the best approaches to endoscopic resection and surveillance, and management of complications, highlighting opportunities for future research to fill gaps in the existing literature.

Methods

This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations.Best Practice Advice Statements

Best Practice Advice 1

Non-neoplastic duodenal lesions (eg, metaplastic foveolar epithelium and gastric heterotopia) may mimic neoplastic adenomatous pathology. Careful optical evaluation and pathologic correlation may be necessary to exclude dysplasia. Nondysplastic lesions do not require endoscopic resection unless they are symptomatic or bleeding.

Best Practice Advice 2

Ideal duodenal endoscopic inspection includes identification of the major and minor papilla with photodocumentation to ensure no involvement by the lesion. Adding a clear distal attachment device to a forward-viewing gastroscope improves visualization of the papilla and the medial wall. A side-viewing duodenoscope should be used when the major and minor papilla are not visible with the gastroscope and for most lesions on the medial wall of the duodenum within 5 cm of the ampulla.

Best Practice Advice 3

All duodenal polyps should be described according to their size, Paris morphology, suspected histologic layer of origin (mucosal lesion or subepithelial lesion), duodenal location (D1–4) and orientation (anterior, posterior, medial, or lateral wall), and proximity/relationship to the major papilla to facilitate therapeutic planning and subsequent surveillance.

Best Practice Advice 4

Given the high frequency of concomitant colonic adenomas in patients with duodenal adenomas, on identification of a duodenal adenoma, a colonoscopy should be performed if a high-quality examination has not been performed in the last 3 years.

Best Practice Advice 5

Routine small bowel investigation (ie, capsule endoscopy) is not advised in patients with sporadic and nonsporadic duodenal adenomas. Periodic small bowel inspection with capsule endoscopy may be of benefit in patients with Peutz-Jeghers syndrome.

Best Practice Advice 6

Definitive treatment of duodenal adenomas by endoscopic resection is less morbid, resource-intensive, and expensive than surgery and is therefore the preferred treatment option.

Best Practice Advice 7

Due to the risk of malignant transformation, all sporadic duodenal adenomas should be considered for endoscopic resection. However, in comparison with colonic adenomas, the time course to malignant transformation may be more prolonged, and the risk of resection-related morbidity much greater. Therefore, the comorbidities and anticipated longevity of the patient must be carefully factored into the decision-making process.

Best Practice Advice 8

The approach to endoscopic duodenal resection (ie, hot vs cold and conventional vs underwater endoscopic mucosal resection) should be individualized to reduce bleeding risk, based on lesion size, morphology, patient comorbidities, and endoscopist comfort level with specific techniques. Piecemeal cold snare resection for flat duodenal adenomas mitigates postprocedural bleeding risk and, for lesions <20 mm, is effective and carries a minimal risk of recurrence. In patients with comorbidities with flat nonbulky lesions measuring < 20 mm, cold snare resection can be considered.

Best Practice Advice 9

Currently, duodenal adenomas >20 mm or with large Paris subtype Is components should be removed by conventional hot snare endoscopic mucosal resection. Thermal ablation of the post–endoscopic mucosal resection margin to mitigate the risk of recurrence to <2%–5% is safe and effective and should be considered.

Best Practice Advice 10

Endoscopists performing duodenal polyp resection should be aware of the increased risk of postprocedural bleeding (compared with elsewhere in the gastrointestinal tract), which usually occurs in the first 48 hours after the procedure, with the risk proportional to the lesion size. For lesions >3 cm, bleeding risk is >25% and may be life-threatening and associated with hemodynamic compromise; however, after resuscitation, endoscopic hemostasis is generally effective.

Best Practice Advice 11

Evaluation of the postpolypectomy/endoscopic mucosal resection defect is critical to identify concerns for postprocedural duodenal perforation, which, if unrecognized and left untreated, may be life-threatening and often mandates surgery.

Best Practice Advice 12

Initial endoscopic surveillance for a completely resected duodenal adenoma should be undertaken at an interval of 6 months. Although usually diminutive, recurrence is often scarred and not amenable to conventional snare resection and may require avulsion techniques to achieve cure.

Best Practice Advice 13

Nonampullary duodenal adenomas associated with familial adenomatous polyposis should be considered for endoscopic resection based on size (≥1 cm), morphologic characteristics, advanced histology (ie, high-grade dysplasia), and/or based on Spiegelman criteria.

中文翻译：

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AGA 非壶腹十二指肠病变临床实践更新：专家审查

 描述

非壶腹十二指肠息肉见于多达 5% 的上消化道内窥镜检查;绝大多数是在无症状患者中偶然发现的。虽然大多数是良性的，但腺瘤估计占这些病变的 10%-20%。大多数国际指南建议应考虑对所有十二指肠腺瘤进行内镜切除术;这可能与前瞻性研究中接近 15% 的不良事件发生率 （主要是出血和穿孔） 有关，监测显示局部复发率很高。本美国胃肠病学协会 （AGA） 临床实践更新专家综述的目的是描述如何评估和分层个体的十二指肠息肉、内窥镜切除和监测的最佳方法以及并发症的管理，强调未来研究填补现有文献空白的机会。

 方法

该专家审查由 AGA 研究所临床实践更新委员会和 AGA 管理委员会委托和批准，旨在就对 AGA 成员具有高度临床重要性的话题提供及时指导，并接受了临床实践更新委员会的内部同行评审和通过胃肠病学标准程序的外部同行评审.这些最佳实践建议声明来自对已发表文献的回顾和专家意见。由于未进行系统评价，这些最佳实践建议声明不对证据质量或所提出考虑因素的强度进行正式评级。最佳实践建议声明

 最佳实践建议 1

非肿瘤性十二指肠病变（如化生性小凹上皮和胃异位）可能类似于肿瘤性腺瘤病变。可能需要仔细的光学评估和病理相关性以排除异型增生。非异型增生病灶不需要内镜切除，除非有症状或出血。

 良好作业建议 2

理想的十二指肠内窥镜检查包括通过照片记录识别头和小，以确保病变不参与。在前视胃镜上添加透明的远端附着装置可改善和内侧壁的可视化。当胃镜看不到头和小时，以及对于十二指肠内侧壁上距离壶腹 5 cm 以内的大多数病变，应使用侧视十二指肠镜。

 最佳实践建议 3

应根据其大小、Paris 形态、可疑的组织学起源层（粘膜病变或上皮下病变）、十二指肠位置 （D1-4） 和方向（前壁、后壁、内侧壁或外侧壁）以及与头的接近/关系来描述所有十二指肠息肉，以利于治疗计划和随后的监测。

 最佳实践建议 4

鉴于十二指肠腺瘤患者伴随结肠腺瘤的发生率很高，在发现十二指肠腺瘤后，如果在过去 3 年内未进行高质量的检查，则应进行结肠镜检查。

 最佳实践建议 5

不建议散发性和非散发性十二指肠腺瘤患者进行常规小肠检查（即胶囊内窥镜检查）。定期使用胶囊内窥镜检查进行小肠检查可能对 Peutz-Jeghers 综合征患者有益。

 最佳实践建议 6

与手术相比，通过内镜切除术对十二指肠腺瘤进行根治性治疗并发症更少、资源密集且费用更高，因此是首选的治疗选择。

 最佳实践建议 7

由于存在恶性转化的风险，所有散发性十二指肠腺瘤都应考虑进行内镜切除术。然而，与结肠腺瘤相比，恶性转化的时间可能更长，并且切除相关并发症的风险要大得多。因此，在决策过程中必须仔细考虑患者的合并症和预期寿命。

 良好作业建议 8

内镜下十二指肠切除术的方法（即热 vs 冷和常规 vs 水下内镜黏膜切除术）应根据病变大小、形态、患者合并症和内镜医师对特定技术的舒适度进行个体化，以降低出血风险。扁平十二指肠腺瘤的零碎冷圈套器切除术可降低术后出血风险，对于病变 <20 mm，有效且复发风险最小。对于合并症为 < 20 mm 的扁平非大块病灶的患者，可考虑冷圈套器切除术。

 良好作业建议 9

目前，十二指肠腺瘤 >20 mm 或具有较大的 Paris 亚型 Is 成分应通过常规热圈套器内窥镜粘膜切除术去除。内窥镜下粘膜切缘热消融以降低复发至 <2%-5% 的风险是安全有效的，应考虑。

 最佳实践建议 10

进行十二指肠息肉切除术的内窥镜医师应意识到术后出血的风险增加（与胃肠道的其他部位相比），出血通常发生在手术后的前 48 小时内，风险与病变大小成正比。对于 >3 cm 的病变，出血风险为 >25%，可能危及生命并与血流动力学损害有关;然而，复苏后，内镜下止血通常是有效的。

 良好作业建议 11

评估息肉切除术/内窥镜黏膜切除缺损对于确定术后十二指肠穿孔的问题至关重要，如果未识别和治疗，可能会危及生命，并且通常需要手术。

 良好作业建议 12

对于完全切除的十二指肠腺瘤，应每隔 6 个月进行一次初始内窥镜监测。虽然复发通常很小，但通常会留下疤痕，不适合传统的圈套器切除术，可能需要撕脱技术才能治愈。

 最佳实践建议 13

与家族性腺瘤性息肉病相关的非壶腹十二指肠腺瘤应考虑根据大小 （≥1 cm）、形态学特征、晚期组织学 （即高度异型增生） 和/或 Spiegelman 标准进行内镜切除。