Endoscopic “Two-Step Method” for resection of a large tumor at the major duodenal papilla

Abstract

Rationale: Endoscopic papillectomy is the standard treatment for noninvasive tumors of the ampulla of Vater. However, reports on the endoscopic resection of large tumors at the major duodenal papilla are rare. The “two-step” endoscopic approach described herein represents the first such report for a giant lesion. Patient concerns: A 75-year-old female patient was admitted to the hospital with a 6-month history of abdominal distension. Gastroscopy revealed a giant tumor in the descending duodenum that prevented clear visualization of its full extent. Diagnoses: Duodenoscopy revealed a laterally spreading tumor, granular homogeneous type (LST-P, Paris 0-IIa), measuring approximately 60 × 50 mm, surrounding the major duodenal papilla. Contrast-enhanced computed tomography showed a 65 × 35 mm intraluminal lesion with no lymphadenopathy. Endoscopic ultrasonography confirmed mucosal and submucosal origin without biliary or pancreatic duct invasion. Biopsy revealed low-grade intraepithelial neoplasia. The final diagnosis was a giant laterally spreading tumor of the major duodenal papilla. Interventions: Endoscopic resection was performed using a novel “Two-Step Method.” In the first session, the bulk of the tumor was resected piecemeal to improve the operative field. Five days later, the residual lesion was resected by endoscopic mucosal resection after submucosal injection. Prophylactic biliary and pancreatic duct stents were placed upon completion of the second session. Outcomes: The patient commenced a cold liquid diet on the second postoperative day. She experienced no abdominal pain, hematochezia, or fever. Histopathology revealed a villous-tubular adenoma with low-grade intraepithelial neoplasia. No adenomatous tissue was identified at the cauterized margins of the submitted specimens. No complications occurred, and no recurrence was observed during the 12-month follow-up. Lessons: Few reports describe the endoscopic treatment of large duodenal tumors. This case demonstrates that the two-step method is a safe and effective alternative for giant duodenal mucosal lesions when single-session resection is precluded by limited operative space. Further experience is needed to establish consensus on the optimal management of such lesions.