The Diagnosis And Treatment Value Of Endoscopic Ultrasonography In Duodenal Submucosal Lesions

ObjectiveWith the development of endoscopic technology,endoscopic ultrasonography(EUS)is increasingly applied in clinical practice.Compared with common endoscopy,which can only observe the mucosal surface,EUS can make a relatively accurate assessment of the size,echo structure and origin level of the lesion by ultrasound,so as to make a relatively accurate judgment of the lesion.For duodenal submucosal lesions(SMLs),the surface status difference of the mucous membrane of different diseases is small,and it's difficult to make differential diagnosis.With the application of EUS to evaluate the internal structure of lesions,we can greatly improve the accuracy of diagnosis.Some studies have already summarized the characteristics of duodenal submucosal lesions,but systematic studies are still lacking.Duodenal gastrointestinal stromal tumors(GIST),as a potentially malignant submucosal lesion,has attracted more and more attention due to its higher detection rate and diagnosis rate with the wide application of endoscopy.Many studies have summarized the clinical characteristics and treatment prognosis of this disease.However,the sample size of most studies is relatively small,and there are conflicting conclusions among different studies.Therefore,in this paper,the value of EUS in the diagnosis and treatment of duodenal SMLs was discussed through systematic induction,and all pathologically diagnosed duodenal stromal tumors were further collected for diagnosis and treatment.MethodsDuring the period of 2008 to 2018,a total of 1587 cases of patients with duodenal SMLs diagnosed by EUS in our hospital were retrospectively collected.After categorizing lesions,the patient's clinical symptoms,serologic test results,CT findings,treatment,pathological results and follow-up were collected and summarized.And we also compared EUS and CT diagnostic value,and treatment success rate,postoperative complications,and long-term prognosis between patients with endoscopic treatment and surgical treatment.In addition,a total of 142 cases in our hospital with pathological diagnosis of duodenal GIST were collected.the patient's clinical symptoms,preoperative CT,MRI and EUS examination results and pathology results conform to the situation,the long-term prognosis of treatment were collected.According to the risk of postoperative risk classification,patients were divided into "very low risk and low risk" group and"intermediate and high risk" group.Clinical characteristics and treatment effect of this two groups were compared.ResultsIn duodenal SMLs diagnosed by EUS,the incidence of each disease was 39.95%for cysts,30.12%for Brunner's gland disease,9.14%for heteropic pancreas,7.69%for the accessory papilla,7.44%for GIST,4.73%for lipoma,and 0.89%for neuroendocrine tumor,respectively.Most of the lesions were solitary.Except the accessory papilla and lipoma,lesions were mostly located in the descending part of duodenum.The positive rate of CT diagnosis was significantly lower than that of EUS,and the positive rate of CT in the treated patients was significantly higher than that in the untreated patients.All patients with GIST were treated with surgery.There was no significant difference between the success rate of endoscopic treatment and surgical treatment for the remaining diseases.The benign lesions such as cyst,Brunner's gland disease,ectopic pancreas,accessory papilla and lipoma were not significantly enlarged during the follow-up.The diagnostic coincidence rate of EUS and pathological results of cyst and GIST was 91.67%and 87.50%,respectively,while that of Brunner's gland disease was only 65.45%.The remaining diseases had a large bias due to the small number of patients treated.Of 142 patients with histopathological diagnosis of primary duodenal GISTs,the most common clinical symptom was gastrointestinal bleeding.The diagnostic accuracy of EUS was significantly higher than that of CT and MRI.Three patients failed to receive endoscopic treatment and were transferred to surgery due to the risk of perforation or failure of ligation.Among 131 patients receiving surgical treatment,the cumulative disease-free survival(DFS)rate of patients in the "intermediate and high risk" group was significantly higher than that in the "extremely low and low-risk" group.In "very low risk and low risk" group,follow-up time,tumor size and mitotic index between patients with limited resection(LR)and pancreaticoduodenectomy(PD)were similar,and there was no significant difference in cumulative DFS.In the "intermediate and high risk" group,LR patients and PD patients had similar follow-up time and mitotic index,but the tumor size of PD patients was significantly larger than that of LR patients.As a result,the cumulative DFS was significantly higher in LR patients than that of PD patients.ConclusionsIn duodenal SMLs,cysts and Brunner's gland disease occurred most frequently,while the remaining diseases were relatively rare.EUS has a high accuracy in the diagnosis of duodenal SMLs,which can help guide the diagnosis and treatment of the disease.But Brunner's gland disease,ectopic pancreas and neuroendocrine tumor all originate from the submucosa with similar EUS manifestations,which were easy to be misdiagnosed.Benign lesions such as accessory papilla,ectopic pancreas,cyst and lipoma,Brunner's gland disease should choose to be followed up regularly.In those SMLs requiring treatment,endoscopic treatment is preferred,except GIST in which surgical treatment is preferred.The diagnostic value of EUS is significantly higher than CT and MRI for duodenal GIST.EUS-FNA can provide a relatively well-trusted histological diagnosis before surgery.And prognosis of duodenal GIST is mainly dependent on tumor biology rather than surgical procedure.