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| CLINICAL IMAGE |
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| Year : 2023 | Volume
: 4
| Issue : 1 | Page : 74-76 |
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A giant duodenal adenoma
Suvendu Sekhar Jena, Amitabh Yadav, Samiran Nundy
Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| Date of Submission | 05-Dec-2022 |
| Date of Acceptance | 31-Dec-2022 |
| Date of Web Publication | 26-Apr-2023 |
Correspondence Address:
Dr. Suvendu Sekhar Jena
Room Number - 1469, Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi - 110 060
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JME.JME_152_22
How to cite this article:
Jena SS, Yadav A, Nundy S. A giant duodenal adenoma. J Med Evid 2023;4:74-6 |
| Introduction | |  |
Sporadic duodenal adenomas are uncommon and have been reported in 0.03% of patients referred for upper gastrointestinal endoscopy.[1] Approximately 40% of them are 'sporadic', and the remaining 60% occur in patients with familial adenomatous polyposis.[2] They are premalignant polyps, but it is difficult to quantify their rate of progression from a low-grade lesion to cancer. Endoscopy and surgery are the currently available modalities for treatment. The available endoscopic options are snare polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection and argon plasma coagulation ablation.[3] Although the endoscopic therapy is less invasive than surgery, its use may be followed by complications such as bleeding, perforation and pancreatitis. Surgical resection is recommended in adenomas with high grade dysplasia, size >2 cm and in elderly patients.[4] The surgical options include transduodenal excision, local full-thickness resection (wedge resection), pancreas-sparing segmental duodenectomy, and pancreaticoduodenectomy.[5] We present here the local excision of a giant adenomatous polyp without performing a major pancreatoduodenectomy.
| Case Report | | |
A 31-year-old female without any comorbidities presented with complaints of mild, non-radiating pain in the upper abdomen for 1½ years without any associated vomiting, jaundice, haematemesis or melaena. She was evaluated with an abdominal ultrasound examination which suggested a wall thickening of the 3rd and 4th parts of the duodenum and a dilated common bile duct (13.5 mm). Triphasic computed tomography of the abdomen showed a distended stomach with a large homogeneously enhancing intraluminal soft tissue lesion in the 2nd and 3rd parts of the duodenum measuring approximately 5.8 cm × 4.4 cm × 9 cm with a vascular pedicle [Figure 1]. Her routine blood investigations and carcinoembryonic antigen and CA 19-9 levels were within normal limits. Fine needle aspiration cytology taken through endoscopic ultrasonography was suggestive of a tubulovillous adenoma with low-grade dysplasia. On upper gastrointestinal endoscopy, there was a large proliferative sessile polyp at the duodenal ampulla. | Figure 1: Computed angiography showing enhancing lesion within the lumen of the duodenum extending up to 3rd part of the duodenum. Black arrow indicates the large adenoma inside duodenum
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We performed a laparotomy through a reverse Makuuchi (L) incision after removing the gallbladder we cannulated the cystic duct with a 4 Fr ureteric catheter and guided it through the ampulla. We then opened the duodenum through a longitudinal incision over the catheter [Figure 2]. The polyp was exteriorised [Figure 3] and we found that there was sufficient distance between its base and the ampulla which would allow ampulla preservation [Figure 4]. The polyp was excised and sent for frozen section analysis. This showed a tubulovillous adenoma with low-grade dysplasia; the base was being free of tumour. The mucosal defect was repaired and the duodenotomy was closed transversely in two layers. The ureteric catheter was kept in place and was removed after 21 days. A pyloric exclusion and posterior gastrojejunostomy was performed to protect the duodenal repair. She made an uneventful recovery and was discharged on the 6th postoperative day. | Figure 2: A polyopidal mass (black arrow) could be seen emanating from duodenotomy orifice with ureteric catheter coming out through via ampulla (grasped with metal forcep)
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 | Figure 3: Entire polypoidal mass coming out from duodenotomy (black arrow)
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 | Figure 4: Entire polypoidal mass in surgeon's hand with adequate distance from ampulla
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The final histopathology showed a tubulovillous adenoma with low-grade dysplasia without any evidence of malignancy [Figure 5]. In the subsequent follow-up after 3 months, she is doing well without any symptoms and has been advised to undergo regular endoscopy every 3 monthly for 2 years and annually thereafter. | Figure 5: Exophytic tumour consisting of closely packed tubular glands with focal villi form projections with focal mucodepletion, nuclear stratification, mild loss of polarity and hyperchromasia in the lining columnar epithelium without any evidence of malignancy
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| Discussion | | |
The rarity of sporadic duodenal adenoma makes it difficult to understand the natural history, although it is known to follow an adenoma to carcinoma sequence similar to colorectal cancer.[6] The rationale for preventive intervention and surveillance is fuelled by the rate of malignant transformation which is reported to be 25%–85%.[7] Majority of them are sessile and occur in the second part of the duodenum. There are two ways to treat these tumours: endoscopic excision and surgical resection. Although endoscopic resection has low morbidity and mortality, it is limited by associated complication, possibility of positive margin, repeated follow-up and cost. Surgical resection provides one-step solution with comparable morbidity and mortality.[8] Most lesions are amenable to endoscopic resections and the recommended endoscopic treatments are (1) endoscopic polypectomy (lesions <1 cm), (2) endoscopic mucosal resection for larger lesions and (3) ablation by Argon Plasma Coagulation. The risk of complications increases with the increase in size of the lesion. It is indicated for lesions <2 cm in size and <33% of duodenal circumference involvement.[8] Bartel et al. compared endoscopic versus surgery in sporadic duodenal adenoma and found negative margin in 100% of surgical patients compared to 53% in endoscopic group.[9] Surgical resection in the form transduodenal excision is recommended for adenomas without high-grade dysplasia, while pancreatoduodenectomy is reserved for high-grade dysplasia and carcinoma. Although pancreatoduodenectomy provides accurate staging and obviates the need for regular follow-up, it has high associated morbidity and mortality. The reported recurrence after transduodenal excision is 10%–35%, which can be minimised by adding intraoperative frozen section or taking 1 cm of normal tissue around the adenoma.[10] Due to rarity, a standard guideline is not available and it depends on institutional preference.
| Conclusion | | |
Sporadic duodenal adenomas, mostly detected incidentally, are precancerous lesions. The management depends on their size, grade of dysplasia and involvement of ductal system. Various surgical options are available starting from limited resections to radical pancreatoduodenectomy. The technique we presented here may help avoid the pancreatoduodenectomy and its associated complications with relative ease.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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