Endoscopic management of NADTs.

We read with great interest the narrative review of Amoyel et al describing endoscopic management of non-ampullary duodenal tumors (NADTs) 1 . As suggested by the authors, the recently published European Society of Gastrointestinal Endoscopy guidelines indicate that endoscopic submucosal dissection (ESD) is an effective resection technique only in expert hands 2 . Indeed, the present review described high perforation and emergency surgery rates for this technique. However, it is important to consider that the higher perforation rate may have mainly been due to intraoperative complications and the endoscopic treatment was successful for closing the defect in most patients. In addition, the authors did not consider one of the largest European series published in 2018 3 , which showed that ESD can be an alternative to endoscopic mucosal resection (EMR) for selected NADTs, such as large duodenal tumors, for which EMR achieves low en-bloc resection rates and the rates of local recurrence may be higher. Similarly, a systematic review and meta-analysis published in Endoscopy International Open in 2018 by our group, which included 14 studies, concluded that ESD may achieve higher rates of en bloc and complete resection compared to duodenal EMR, without statistically significant differences in delayed perforation rates for the two techniques 4 . Finally, the rate of complications associated with duodenal ESD has been gradually decreasing and appropriate treatment should be chosen according to lesion characteristics and local experience 5 .

Thus, the conclusion of the authors stating that “ESD has a limited contribution in management of duodenal adenomas” seems, from our perspective, very risky. This conclusion did not consider previous meta-analysis on this topic and is mainly based on non-pooled data about the intraoperative perforation rate, which probably has a low impact on clinically relevant outcomes, such as emergency surgery.