Safety and Feasibility of Laparoscopic and Endoscopic Cooperative Surgery With Endoscopic Submucosal Dissection for Large Superficial Non-Ampullary Duodenal Epithelial Tumors.

Background and Aims: Endoscopic submucosal dissection (ESD) for large superficial non-ampullary duodenal epithelial tumors (SNADETs) poses substantial technical challenges, primarily because of a heightened risk of adverse events (AEs). Laparoscopic and endoscopic cooperative surgery (D-LECS) was introduced to address these risks, with recent advancements extending its application to larger tumors, including those on the pancreatic side of the duodenum. This study evaluated the safety and feasibility of D-LECS combined with ESD and seromuscular reinforcement for large SNADETs (≥ 30 mm). Methods: This retrospective study included patients diagnosed with SNADETs who underwent D-LECS with ESD from October 2013 to October 2023. The primary outcome was the incidence of AEs graded Clavien-Dindo II or higher. Secondary outcomes included delayed perforation, delayed bleeding, delayed gastric emptying, stenosis, intra-abdominal fluid collection, and rates of Results: Fifty patients were analyzed: 19 with tumors ≥ 30 mm, 31 with tumors < 30 mm, and 21 requiring pancreatic-side dissection. Primary AE incidence was 6.5% (95% CI: 1.8-20.7) for tumors < 30 mm, 5.3% (95% CI: 0.9-24.6) for tumors ≥ 30 mm, 6.9% (95% CI: 1.9-22.0) without pancreatic-side dissection, and 4.8% (95% CI: 0.8-22.7) with pancreatic-side dissection. Secondary outcomes indicated no increased risk from tumor size or pancreatic-side dissection. Conclusions: D-LECS with ESD and seromuscular reinforcement represents a safe and feasible strategy for large SNADETs, including pancreatic-side lesions, with minimal AE rates, supporting its broader application.