Management of non-ampullary duodenal adenomas

Non-ampullary duodenal adenomas (NADAs) are increasingly recognised because of improvements in endoscopy quality and the rising number of procedures performed. NADAs are premalignant lesions that follow an adenoma–carcinoma sequence; therefore, endoscopic resection is usually recommended. However, decision-making regarding endoscopic resection remains complex because of the challenging duodenal anatomy, evolving resection technologies and the high risk of complications in this location.

This review aims to provide a comprehensive, evidence-based synthesis of current knowledge regarding the management of NADAs. We examine epidemiology, natural history, endoscopic assessment techniques, indications for intervention, resection techniques, adverse event management, outcomes and recurrence patterns.

High-quality evidence remains limited because of the relative rarity of these lesions. Although several classification systems for endoscopic characterisation have been developed for colorectal polyps, corresponding classifications for NADAs remain less well developed and are not widely embedded in routine practice. Cold snare resection techniques are well established for small NADAs, while emerging evidence supports the expanding role of cold endoscopic mucosal resection (EMR) for selected intermediate-sized lesions because of its favourable safety profile. Hot EMR remains an established and widely available approach for larger or more complex lesions. Experience with endoscopic submucosal dissection is increasing, although it is generally reserved for selected NADAs in which en bloc R0 resection is required, particularly lesions with suspected focal high-grade dysplasia or invasion and should be performed in high-volume expert centres because of its substantial procedural risk. Complications in the duodenum can have devastating consequences compared with other areas of the gastrointestinal tract. A tailored approach balancing safety, oncological outcomes, operator experience and healthcare resources is therefore advised.