Structured Closure Improves Safety of Duodenal ESD and EFTR : GIE | April 2026

Introduction:

Endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR) have expanded the therapeutic options for duodenal epithelial and sub epithelial lesions, allowing organ-preserving treatment of lesions that previously required surgery. However, the duodenum remains one of the most technically challenging locations for advanced endoscopic resection because of its thin wall, narrow lumen, rich vascularity, and exposure to bile and pancreatic secretions. These anatomical factors increase the risk of bleeding, perforation, and delayed adverse events.

Problem Statement:

Although ESD and EFTR are increasingly performed in expert centers, data regarding real-world outcomes, predictors of complications, and strategies to reduce delayed adverse events remain limited. Identifying high-risk lesions and optimizing defect closure techniques are critical to improving procedural safety.

Summary:

This real-world study demonstrates that both ESD and free-hand EFTR can be performed with high technical success and excellent oncologic outcomes for carefully selected duodenal lesions. The investigators achieved high rates of complete resection while maintaining low recurrence rates during follow-up. Importantly, all intraprocedural bleeding and perforation events were successfully managed endoscopically, highlighting the feasibility of advanced endoscopic therapy in experienced hands. A key finding of the study was the identification of severe fibrosis as the strongest predictor of procedural adverse events in sub epithelial lesions, particularly when associated with ulceration. These features may therefore serve as valuable markers for procedural complexity and risk stratification before intervention. The study also underscores the importance of meticulous defect management. By implementing a structured closure protocol that incorporated stepwise closure techniques, intraoperative assessment, and selective postprocedural imaging, the investigators achieved near-complete defect closure and remarkably low rates of delayed complications. This finding is particularly relevant because delayed perforation and bleeding remain major concerns after duodenal resection. Overall, the study supports ESD and EFTR as effective minimally invasive alternatives to surgery for selected duodenal lesions and suggests that a systematic closure strategy may be a critical factor in enhancing procedural safety. These results provide a practical framework for optimizing outcomes in advanced duodenal endoscopic resection.