Endoscopic resection by mucosal resection (EMR) is the ESGE-recommended therapy for treatment of non-ampullary duodenal adenomas. Other important aspects of management include surveillance for recurrence, and colonic evaluation. While procedural outcomes from EMR are established, the application of follow-up and surveillance is less clear. We reviewed a decade of practice to benchmark local outcomes against guidelines and identify pathway improvement opportunities within our tertiary endoscopy referral centre.

Ten year retrospective evaluation of all non-ampullary duodenal adenomas ≥10 mm resected between 2014–2024. Data were obtained from electronic patient records and endoscopy procedure databases. Procedural safety, recurrence, and adherence to ESGE surveillance pathways and colonic evaluation guidance were assessed, including comparisons before and after the 2021 ESGE guideline update.

A total of 78 adenomas in 64 patients were resected by EMR within the evaluation period.  Of these, 44 patients had sporadic adenomas and the remainder a polyposis syndrome (16 FAP, 3 Peutz-Jaeghers, 1 MUTYH). In the adenoma group, en-bloc resection was achieved in 28/78 (35.9%). Margins were R0 in 17/78 (21.8%), R1 4/78 (5.1%), and Rx 57/78 (73.1%), reflecting use of piecemeal EMR. 

 Delayed bleeding occurred in 3/78 (3.8%), and perforation in 0 patients. All of the bleeding events occurred in adenomas ≥30 mm (p=0.006), suggesting a size-dependent risk. Clip closure was performed in 26/78 (33.3%) and haemostatic forceps and / or topical haemostatic agent in 17/78 (21.8%).  

Endoscopic surveillance after index treatment was variable with 44/64 (68.8%) patients undergoing first surveillance within one year. Residual adenoma was found in 6/64 (9.4%) patients which were treated endoscopically. Persistent residual adenoma was seen at second follow in one patient which was cleared successfully with no recurrence on subsequent examinations. Residual rates were higher for patients with adenomas ≥30mm (23.1% v 4.6%, p=0.023). 

With regards to colonic surveillance algorithms; of those with sporadic adenoma, colonic evaluation was completed in 27/44 (61.4%). Of these, 5/44 (11.4%) cases of synchronous colorectal cancer were identified.  

EMR is highlighted in our evaluation as a safe and effective technique in our institution for the management of non-ampullary duodenal adenomas. Low bleeding rates can be achieved with selective use on a case-by-case basis of adjunctive prophylactic techniques. There are important learning points from our evaluation regarding historical deviation from current ESGE guidelines. 

Surveillance programs after resection have followed different intervals to the current recommended standards introduced in the 2021 guidance. Given significant rates of residual disease in those with resection of larger adenomas (≥30 mm), adherence to these guidelines is important. Residual disease can then be treated successfully with good outcomes as demonstrated in our data.  

The ESGE guidance recommends performance of a colonoscopy in cases of duodenal adenoma. The importance of this is highlighted in our study by findings of high rates of synchronous colorectal cancer in our cohort in those without polyposis syndromes. Despite this, a significant proportion of patients did not have any colonic evaluation suggesting the need for standardised local pathways to optimise adherence with guidelines.