Prophylactic endoscopic resection of duodenal adenomas effectively prevented cancer in a cohort of patients with familial adenomatous polyposis (FAP), according to study results published in Gastrointestinal Endoscopy. However, papillectomies were associated with substantial adverse events, emphasizing the importance of careful risk-benefit analysis for patients in this cohort.
Researchers conducted a retrospective cohort study of patients with FAP who underwent endoscopic duodenal intervention between 2002 and 2018 at a clinic in Amsterdam, the Netherlands. FAP had been diagnosed either genetically or through the clinical observation of over 100 colorectal adenomas. The researchers abstracted demographic and endoscopic data from patient medical records. Exposures of interest were surgical intervention through duodenal polypectomy or papillectomy. Indications for duodenal polypectomy were: size ≥10 mm, high grade dysplasia on biopsy, or an aim of decreasing Spigelman stage. Indications for papillectomy were: size ≥10 mm, progressive growth, or high grade dysplasia on biopsy. The primary outcomes were effectiveness and safety of duodenal polypectomies and papillectomy.
The study cohort comprised 224 patients with FAP, of whom 67 (30%) had undergone at least 1 endoscopic duodenal intervention. Of these patients, 38 underwent at least 1 duodenal polypectomy and 18 underwent a papillectomy. In total, only 1 patient had undergone both types of procedure. Of patients who underwent duodenal polypectomies, median age was 43 years and 41% were men. In the papillectomy group, median age was 49 years and 48% were men. The most frequent indication for duodenal polypectomy was adenoma size ≥10 mm.
Overall, 139 duodenal adenomas were removed over 68 procedures. Follow-up data were available for 50 (74%) of these sessions. Duodenal surgery-free and cancer-free survival after polypectomy was 97% at 12 months, 86% at 24 months, and 74% at 89 months. Overall, 13 adverse events were observed across 68 procedures, 11 of which resulted in prolonged hospitalization. Delayed bleeding was the most common adverse event (n=9), and only occurred after resection of lesions >20mm. Only 1 patient had been using anticoagulants prior to surgery. In total, 3 patients received blood transfusions and 2 were admitted to intensive care following delayed bleeding.
A total of 29 papillectomies were performed. Follow-up data were available for 23 (79%) of these. Surgery- and cancer-free survival after papillectomy was 96% at 12 months, 91% at 24 months, 79% at 60 months, and 71% at 71 months. Compared with polypectomies, papillectomies had more frequent and severe adverse events. A total of 12 adverse events were observed over 29 procedures: 6 delayed bleedings; 4 cases of pancreatitis; 1 perforation; and 1 case of fever caused by Klebsiella pneumoniae infection. Delayed bleeding resulted in prolonged hospitalization and endoscopic re-intervention in all 6 cases; blood transfusions were required in 3 patients. Two of 4 patients with pancreatitis required prolonged hospitalization.
According to these data, duodenal polypectomy and papillectomy were effective means of preventing cancer development in patients with FAP. However, both procedure types had substantial risk of adverse events. Careful consideration of the risks and benefits of endoscopic intervention—particularly papillectomy—is essential for patients with FAP.
The primary study limitation is its retrospective design, which limited the availability and duration of follow-up data. “These data on prophylactic duodenal interventions in FAP are promising and prospective data on treatment and surveillance may in the future confirm an actual decrease of duodenal cancer risk as well as the surveillance burden,” investigators wrote.
Disclosure: Several study authors declared affiliations with the pharmaceutical industry.
Please see the original reference for a full list of authors’ disclosures.
Roos VH, Bastiaansen BA, Kallenberg FGJ, et al. Endoscopic management of duodenal adenomas in patients with familial adenomatous polyposis [published online June 11, 2020]. Gastrointest Endosc. doi: 10.1016/j.gie.2020.05.065