Endoscopic submucosal dissection in the duodenum: Ready for prime time?

We thank Enrique Perez-Cuadrado-Robles and Pierre Deprez for their comments. We concur with them on the fact that delayed perforation represents a minority (10 %–20 %) of all perforations after duodenal ESD 1 2 3 . In our eyes, however, this number is unacceptably high, considering that management of such patients can require emergent duodenopancreatectomy and is associated with significant morbidity. In addition, perprocedural perforations during duodenal ESD are very different from those occurring during resections in other parts of the gastrointestinal tract: In a series of 36 duodenal perforations after ESD, Fukuhara et al. showed that complete endoscopic closure of an intraoperative perforation, even in expert hands, was only achieved in 41 % of patients, resulting in long and complex medical management, with a median (range) of 12 days (4–58) of hospital admission in these patients 1 .

The valuable work of Perez-Cuadrado-Robles et al. reporting the outcomes of one of the only European studies of duodenal ESD outside Japan, however, concurs with our statement, since: 1) It failed to demonstrate any benefit of duodenal ESD over duodenal endoscopic mucosal resection (EMR) in terms of en bloc resection, complete resection, or local recurrence rate; and 2) It did show a seven times higher (and statistically significant) risk of duodenal perforation with duodenal ESD over EMR 2 .

In the second self-cited work by Perez-Cuadrado-Robles et al., including 784 lesions among 14 studies, the authors again did not show the clinical benefit of duodenal ESD, since the ultimate goal of en bloc resection – prevention of local recurrence – was not achieved significantly better with ESD over EMR 4 .

Finally, we agree with the fact that all the studies on duodenal ESD show a learning curve effect, involving the endoscopists’ experience, and possibly a better selection of lesions 5 . However, in 2022, we believe that the “risky” conclusion would be to promote liberal use of ESD for resection of duodenal adenomas.