Supplementary Material for: Factors related to delayed adverse events of endoscopic submucosal dissection in the duodenum

Introduction: Endoscopic submucosal dissection for duodenal neoplasms (D-ESD) is considered a technically demanding procedure regarding the high risk of delayed adverse events. Data regarding optimal managements of ulcers after D-ESD are lacking. Methods: A retrospective analysis was performed on consecutive 145 cases of D-ESD for superficial non-ampullary duodenal epithelial tumors at a single referral center. Factors related to delayed adverse events and the healing process of ulcers after D-ESD were analyzed. Results: Complete ulcer suture after D-ESD was performed in 128 cases (88%). Two delayed perforation occurred among cases with incomplete suture. Delayed bleeding occurred in 8 cases (6%) within three weeks. The ulcer closure rate at second-look endoscopy was significantly low among cases with delayed bleeding (12.5% vs 75%, P=0.001). The bleeding rate before second-look endoscopy was significantly high among patients who did not have complete ulcer closure after D-ESD (0.8% vs 12%, P=0.036). The ratio of lesions located in the 2nd oral-Vater was significantly low among ulcers re-opened at second-look endoscopy (38% vs 14%, P=0.044). Proton-pump inhibitors (PPI) were administered for a median of seven weeks (range 1-8 weeks). At three weeks, active ulcer stages were observed in a few cases, and healing or scarring was observed in most cases. Conclusions: Complete ulcer suture was related to decreased risk of delayed adverse events after D-ESD. From the bleeding period and healing process of D-ESD ulcers, the minimum required length of PPI may be three weeks after D-ESD.

引言：十二指肠肿瘤内镜黏膜下剥离术（duodenal endoscopic submucosal dissection, D-ESD）因延迟不良事件风险较高，被视为一项技术难度较大的手术。目前关于D-ESD术后溃疡的最优管理方案仍缺乏相关数据。
方法：本研究对单转诊中心连续纳入的145例行浅表性非壶腹十二指肠上皮肿瘤D-ESD的病例开展回顾性分析，探讨与D-ESD术后延迟不良事件相关的影响因素及术后溃疡的愈合过程。
结果：128例（88%）患者完成了术后溃疡完整缝合。缝合不全的病例中出现2例延迟性穿孔。术后3周内共有8例（6%）患者发生延迟性出血。在发生延迟性出血的病例中，复查内镜下的溃疡闭合率显著更低（12.5% vs 75%，P=0.001）。D-ESD术后未完成溃疡完整缝合的患者，复查内镜前的出血发生率显著更高（0.8% vs 12%，P=0.036）。复查内镜下发现溃疡再开放的病例中，病变位于十二指肠第二段（口侧至壶腹部）的比例显著偏低（38% vs 14%，P=0.044）。质子泵抑制剂（PPI）的中位给药时长为7周（范围1~8周）。术后3周时，仅少数患者仍处于活动期溃疡阶段，多数患者已出现溃疡愈合或瘢痕形成。
结论：D-ESD术后完成溃疡完整缝合可降低术后延迟不良事件的发生风险。结合D-ESD术后溃疡的出血发生规律与愈合过程，质子泵抑制剂（PPI）的最短推荐使用时长可能为术后3周。