Treatment of 2.5 cm Polyp Proximal to Ampulla in D2
A 2.5 cm polyp in the second part of the duodenum (D2) proximal to the ampulla should be treated with endoscopic mucosal resection (EMR) using conventional hot snare technique, with thermal ablation of the post-resection margin to reduce recurrence risk below 5%. 1
Primary Treatment Approach
Endoscopic resection is the definitive treatment of choice for this lesion, as it is less morbid, resource-intensive, and expensive than surgery. 1 The 2025 AGA guidelines specifically recommend conventional hot snare EMR for duodenal adenomas >20 mm (your polyp is 25 mm). 1
Technical Considerations for Resection
Use conventional hot snare EMR rather than cold snare for this size lesion, as cold snare is only recommended for flat lesions <20 mm. 1
Apply thermal ablation to the post-EMR margin after complete resection to reduce recurrence risk to <2-5%. 1
Ensure complete documentation of the lesion's relationship to the major and minor papilla with photodocumentation to confirm no ampullary involvement. 1
Perform piecemeal resection if needed, recovering all polyp fragments for complete histologic assessment. 2
Critical Pre-Procedure Requirements
Before attempting resection, the endoscopist must:
Confirm the polyp is truly non-ampullary using both forward-viewing gastroscope and side-viewing duodenoscope to visualize the ampulla and ensure no papillary involvement. 1
Assess patient comorbidities and life expectancy, as the risk of resection-related morbidity in the duodenum is substantially greater than in the colon, and malignant transformation may be more prolonged than colonic adenomas. 1
Ensure the procedure is performed by an experienced endoscopist, as duodenal EMR requires proficiency in both resection and mucosal defect closure techniques. 1
Major Complications to Anticipate
Post-Procedural Bleeding (Most Common)
Bleeding risk for lesions 2-3 cm is approximately 15-25%, occurring primarily within the first 48 hours post-procedure. 1
Patients require close monitoring for 48 hours after the procedure, with readiness for endoscopic hemostasis if bleeding occurs. 1
After resuscitation, endoscopic hemostasis is generally effective for managing post-polypectomy bleeding. 1
Perforation Risk
Immediate perforation during resection can occur due to the thin duodenal wall and exposure to proteolytic pancreatic enzymes. 1
Delayed perforation may occur hours to days after the procedure from enzymatic digestion of the mucosal defect. 1
Careful evaluation of the post-EMR defect is critical to identify concerns for perforation, which if unrecognized and untreated may be life-threatening and often mandates surgery. 1
For perforations <2 cm, use through-the-scope clips (TTSCs) or over-the-scope clips (OTSCs) for immediate closure. 1
Post-Resection Management
Immediate Post-Procedure Care
Consider water-soluble upper GI series before initiating clear liquid diet to confirm absence of continuing leak. 1
Maintain NPO status initially with gradual diet advancement based on clinical stability and absence of complications. 1
Monitor for signs of bleeding or perforation including vital signs, abdominal examination, and hemoglobin levels. 1
Surveillance Strategy
Perform first surveillance endoscopy at 6 months after complete resection to assess for recurrence. 1
Recurrence, though usually diminutive, is often scarred and may require avulsion techniques rather than conventional snare resection. 1
Thermal ablation of margins significantly reduces recurrence to <2-5%, making surveillance findings more favorable. 1
When to Consider Surgery Instead
Surgery should be considered if:
The polyp involves or is immediately adjacent to the ampulla, requiring Whipple procedure or similar complex resection. 1
Endoscopic resection is not technically feasible due to location, size, or morphology making complete resection impossible. 1
Biopsy reveals invasive carcinoma requiring oncologic resection with lymph node dissection. 2, 3
Patient develops perforation with peritoneal signs or hemodynamic instability that cannot be managed endoscopically. 1
Important Caveats
Avoid routine biopsy before planned resection, as it induces submucosal scarring that makes subsequent EMR more difficult and increases perforation risk. 4, 5
The duodenal location carries inherently higher risk than colonic polypectomy due to thinner walls, narrow lumen, and proximity to critical structures. 6
Unsuspected cancer is found in approximately 10% of large duodenal polyps, making complete fragment recovery and histologic assessment essential. 2
For lesions >3 cm, bleeding risk exceeds 25% and may be life-threatening with hemodynamic compromise, requiring intensive monitoring. 1