Miyazaki Kurato, Yahagi Naohisa, Kato Motohiko
Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan.
Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.
Digestion. 2025 Jul 21:1-15. doi: 10.1159/000547461.
Superficial non-ampullary duodenal epithelial tumors (SNADETs) were previously considered rare. However, the widespread use of health checkup endoscopy, improvements in endoscopic imaging and heightened awareness of SNADETs among endoscopists have recently led to an increase in their detection rate. Particularly for large SNADETs, the possibility of including cancer must be considered, and thus, complete and reliable resection is essential. Although surgical resection has traditionally been the standard treatment, its high invasiveness has led to increased interest in less invasive endoscopic treatments. Nevertheless, due to the unique anatomical and physiological features of the duodenum, endoscopic treatment in the duodenum remains highly challenging and presents many technical difficulties.
This review provides a comprehensive overview of current endoscopic treatment options for large SNADETs, including conventional endoscopic mucosal resection (C-EMR), underwater endoscopic mucosal resection (U-EMR), cold snare endoscopic mucosal resection (CS-EMR), endoscopic submucosal dissection (ESD), and laparoscopic-endoscopic cooperative surgery, incorporating the latest clinical findings. While C-EMR, U-EMR, and CS-EMR are associated with lower technical difficulty and favorable safety, they tend to show lower en bloc resection rates and higher recurrence rates for large SNADETs when compared to ESD. In contrast, ESD offers higher en bloc resection rates but carries a greater risk of complications due to its technical complexity. To overcome these limitations, several techniques have been developed, such as the pocket-creation method, water pressure method, improved closure strategies for mucosal defects, and drainage with endoscopic nasobiliary and pancreatic drainage to prevent exposure to pancreatic juice and bile.
Multiple endoscopic strategies are available for the treatment of large SNADETs. However, due to the rarity of the disease and variation in institutional expertise, a standardized treatment strategy has not yet been established. Endoscopic treatment for large SNADETs is technically very challenging and carries a high risk. Therefore, careful consideration of the indication for each treatment method, along with a full understanding of their respective advantages and disadvantages, is essential. In recent years, the safety of endoscopic resection has been gradually improving due to various technical innovations and better management of adverse events, making ESD, which offers a high en bloc resection rate, an increasingly reasonable treatment option.
浅表非壶腹十二指肠上皮肿瘤（SNADETs）既往被认为较为罕见。然而，健康体检内镜检查的广泛应用、内镜成像技术的改进以及内镜医师对SNADETs认识的提高，近来导致其检出率上升。特别是对于较大的SNADETs，必须考虑包含癌变的可能性，因此，完整且可靠的切除至关重要。虽然传统上手术切除一直是标准治疗方法，但其高侵袭性已使人们对侵入性较小的内镜治疗兴趣增加。尽管如此，由于十二指肠独特的解剖和生理特征，十二指肠的内镜治疗仍然极具挑战性且存在许多技术难题。
本综述全面概述了目前用于治疗较大SNADETs的内镜治疗选择，包括传统内镜黏膜切除术（C-EMR）、水下内镜黏膜切除术（U-EMR）、冷圈套器内镜黏膜切除术（CS-EMR）、内镜黏膜下剥离术（ESD）以及腹腔镜-内镜联合手术，并纳入了最新的临床研究结果。虽然C-EMR、U-EMR和CS-EMR技术难度较低且安全性良好，但与ESD相比，对于较大的SNADETs，它们的整块切除率往往较低且复发率较高。相比之下，ESD整块切除率较高，但由于其技术复杂性，并发症风险更大。为克服这些局限性，已开发了多种技术，如造袋法、水压法、改进的黏膜缺损闭合策略以及采用内镜鼻胆管引流和胰管引流以防止暴露于胰液和胆汁。
有多种内镜策略可用于治疗较大的SNADETs。然而，由于该疾病罕见且各机构专业水平存在差异，尚未建立标准化的治疗策略。较大SNADETs的内镜治疗在技术上极具挑战性且风险较高。因此，仔细考虑每种治疗方法的适应证，并充分了解其各自的优缺点至关重要。近年来，由于各种技术创新和对不良事件的更好管理，内镜切除的安全性已逐渐提高，使得整块切除率较高的ESD成为越来越合理的治疗选择。
