Outcomes of cold snare piecemeal EMR for nonampullary small-bowel adenomas larger than 1 cm: a retrospective study

Outcomes of cold snare EMR of nonampullary duodenal adenomas ≥1 cm: a multicenter study

BACKGROUND AND AIMS

Endoscopic mucosal resection (EMR) with use of electrocautery (conventional EMR) has historically been used to remove large duodenal adenomas; however, use of electrocautery can predispose to adverse events including delayed bleeding and perforation. Cold snare EMR (cs-EMR) has been shown to be safe and effective for removal of colon polyps, but data regarding its use in the duodenum are limited. The aim of this study was to evaluate the efficacy and safety of cs-EMR for nonampullary duodenal adenomas ≥1 cm.

METHODS

This was a multicenter retrospective study of patients with nonampullary duodenal adenomas ≥1 cm who underwent cs-EMR from October 2014 to May 2023. Patients who received any form of thermal therapy were excluded. Primary outcomes were technical success and rate of recurrent adenoma. Secondary outcomes were adverse events and predictors of recurrence.

RESULTS

A total of 125 patients underwent resection of 127 nonampullary duodenal adenomas with cs-EMR. Follow-up data were available in 89 cases (70.1%). The recurrent adenoma rate was 31.5% (n = 28). Adverse events occurred in 3.9% (n = 5), with 4 cases of immediate bleeding (3.1%) and 1 case of delayed bleeding (.8%). There were no cases of perforation. The presence of high-grade dysplasia was found to be an independent predictor of recurrence (odds ratio, 10.9 [95% confidence interval, 1.1-102.1]; P = .036).

CONCLUSIONS

This retrospective multicenter study demonstrates that cs-EMR for nonampullary duodenal adenomas is safe and technically feasible with an acceptable recurrence rate. Future prospective studies are needed to directly compare outcomes of cs-EMR with conventional and underwater EMR.

Cold-snare endoscopic resection of non-ampullary duodenal adenomas: Systematic review and pooled-analysis

BACKGROUND

Mirroring the experience with colonic resections, cold snare-based techniques have been recently proposed for non-ampullary duodenal lesions to reduce the risk of adverse events (AEs). As the duodenal wall is thinner and more vascularized than in the colon, electrocautery-related AEs are relevant issues in this setting.

AIMS

We performed a systematic review with pooled-analysis to evaluate the efficacy and safety of this technique.

METHODS

Electronic databases (Medline, Scopus, EMBASE) were searched up to January 2023. Full articles including patients with duodenal lesions resected by cold-snare technique were eligible. The adverse events (i.e., bleeding, perforation, stricture), complete resection, and recurrence rates were pooled using a random model.

RESULTS

Eleven studies were eligible, providing data on 3137 lesions removed from 233 patients. The overall AE rate for cold snaring was 0.25% (95% CI, 0.19%-0.69%). Among the three studies comparing cold- and hot-snare approaches, procedure-related bleeding rate was significantly lower with cold approach (OR 1.21, 0.51-2.85; p = 0.66). The complete resection rate was 99.40% (95% CI, 98.60%-100%), with a residual/recurrence rate of 12.95% (95% CI, 4.75%-21.16%). On univariate meta-regression, lesion size significantly affected both the adverse events and recurrence risk.

CONCLUSION

Cold-snare resection appears effective and extremely safe for resecting non-ampullary duodenal lesions.

Cold snare resection for non-ampullary sporadic duodenal adenomas: systematic review and meta-analysis

Background and study aims The role of cold snare polypectomy (CSP) in curative resection of non-ampullary sporadic duodenal adenomas (NASDA) is debated. We conducted a systematic review and meta-analysis to investigate the efficacy and safety of CSP for NASDA. Patients and methods In this systematic review and meta-analysis, we identified published series of patients with CSP for NASDA by searching PubMed and Google Scholar, which resulted in six papers (205 lesions). The main outcome was the rate of local remission after repeated CSP, the secondary outcomes were rates of local remission at first control and rates for delayed bleeding and immediate perforations. We computed the weighted summary proportions under the fixed and random effects model. Results The pooled proportion of local remission after repeated CSP was 88% (95% confidence interval [CI] 57%-100%). The pooled proportion of local remission at first control was 81% (95% CI 55%-98%), the pooled proportion of delayed bleeding was 1% (95% CI 0%-4%) and the pooled proportion of immediate perforation was 0% (95% CI 0%-2%). Conclusions Our meta-analysis suggests that CSP should be considered as the first-line therapy for NASDA.

Cold snare polypectomy for duodenal adenomas in familial adenomatous polyposis: a prospective international cohort study

Background and study aims In patients with familial adenomatous polyposis (FAP), endoscopic resection of duodenal adenomas is commonly performed to prevent cancer and prevent or defer duodenal surgery. However, based on studies using different resection techniques, adverse events (AEs) of polypectomy in the duodenum can be significant. We hypothesized that cold snare polypectomy (CSP) is a safe technique for duodenal adenomas in FAP and evaluated its outcomes in our centers. Patients and methods We performed a prospective international cohort study including FAP patients who underwent CSP for one or more superficial non-ampullary duodenal adenomas of any size between 2020 and 2022. At that time, this technique was common practice in our centers for superficial duodenal adenomas. The primary outcome was the occurrence of intraprocedural and post-procedural AEs. Results In total, 133 CSPs were performed in 39 patients with FAP (1-18 per session). Median adenoma size was 10 mm (interquartile range 8-15 mm), ranging from 5 to 40 mm; 27 adenomas were ≥20 mm (20%). Of the 133 polypectomies, 109 (82%) were performed after submucosal injection. Sixty-one adenomas (46%) were resected en bloc and 72 (54%) piecemeal. Macroscopic radical resection was achieved for 129 polypectomies (97%). Deep mural injury type II occurred in three polyps (2%) with no delayed perforation after prophylactic clipping. There were no clinically significant bleeds, perforations or other post-procedural AEs. Histopathology showed low-grade dysplasia in all 133 adenomas. Conclusions CSP for (multiple) superficial non-ampullary duodenal adenomas in FAP seems feasible and safe. Long-term prospective research is needed to evaluate whether protocolized duodenal polypectomies prevent cancer and surgery.

Efficacy and Safety of Cold Snare Endoscopic Mucosal Resection (CS-EMR) for Nonampullary Duodenal Polyps: Systematic Review and Meta-Analysis

INTRODUCTION

There is an increasing interest in cold snare endoscopic mucosal resection (CS-EMR), and studies have shown its safety and efficacy for colonic polyps. This meta-analysis aims to assess the safety and efficacy of CS-EMR for the removal of duodenal adenomas.

METHODS

We conducted a comprehensive literature search of several databases, from inception through February 2023, for studies that addressed outcomes of CS-EMR for nonampullary duodenal adenomas. We used the random-effects model for the statistical analysis. The weighted pooled rates were used to summarize the technical success, polyp recurrence, bleeding, and perforation events. Cochran Q test and I2 statistics adjudicated heterogeneity.

RESULTS

Six studies were included in the analysis. In all, 178 duodenal polyps were resected using CS-EMR. The pooled rates were 95.8% (95% CI 89.1-98.5%, I2=21.5%) for technical success and 21.2% (95% CI 8.5-43.6%, I2=78%) for polyp recurrence. With regards to CS-EMR safety, the pooled rates were 4.2% (95% CI 1.6-10.5%, I2=12%) for immediate bleeding, 3.4% (95% CI 1.5-7.6%, I2=0%) for delayed bleeding, 2.8% (95% CI 1.1-6.7%, I2=0%) for perforation, and 2% (95% CL 0.5-7.5%, I2=0%) for post-polypectomy syndrome. Rates were not significantly different for large adenomas. Three studies reported data on CS-EMR and conventional EMR. Compared with conventional EMR, CS-EMR had lower odds of delayed bleeding, OR 0.11 (CI 0.02-0.62, P value 0.012, I2=0%).

CONCLUSION

Our findings suggest that CS-EMR is a safe and effective strategy for the resection of nonampullary duodenal adenomas, with an acceptable recurrence rate. Data from larger randomized controlled studies are needed to validate our findings.

Updates in the diagnosis and management of small-bowel tumors

Small-bowel tumors represent a rare entity comprising 0.6% of all new cancer cases in the US, and only 3% of all gastrointestinal neoplasms. They are a heterogenous group of neoplasms comprising of about forty different histological subtypes with the most common being adenocarcinoma, neuroendocrine tumors, stromal tumors and lymphomas. Their incidence has been reportedly increasing over recent years, partly owing to the advances and developments in the diagnostic modalities. Small-bowel capsule endoscopy, device assisted enteroscopy and dedicated small-bowel cross-sectional imaging are complimentary tools, supplementing each other in the diagnostic process. Therapeutic management of small-bowel tumors largely depends on the histological type and staging at diagnosis. The aim of the present review article is to discuss relevant advances in the diagnosis and management of small-bowel tumors.

Endoscopic resection of non-ampullary duodenal adenomas: Is cold snaring the promised land?

Due to the high risk of morbidity and mortality associated with surgical resection in this tract, endoscopic resection (ER) has taken the place of surgical resection as the first line treatment for non-ampullary duodenal adenomas. However, due to the anatomical characteristics of this area, which enhance the risk of post-ER problems, ER in the duodenum is particularly difficult. Due to a lack of data, no ER technique for superficial non-ampullary duodenal epithelial tumours (SNADETs) has yet been backed by strong, high-quality evidence; yet, traditional hot snare-based techniques are still regarded as the standard treatment. Despite having a favourable efficiency profile, adverse events during duodenal hot snare polypectomy (HSP) and hot endoscopic mucosal resection, such as delayed bleeding and perforation, have been reported to be frequent. These events are primarily caused by electrocautery-induced damage. Thus, ER techniques with a better safety profile are needed to overcome these shortcomings. Cold snare polypectomy, which has already been shown as a safer, equally effective procedure compared to HSP for treatment of small colorectal polyps, is being increasingly evaluated as a potential therapeutic option for non-ampullary duodenal adenomas. The aim of this review is to report and discuss the early outcomes of the first experiences with cold snaring for SNADETs.

Endoscopic Surveillance and Treatment of Upper GI Tract Lesions in Patients with Familial Adenomatous Polyposis-A New Perspective on an Old Disease

Familial adenomatous polyposis (FAP) is an autosomal dominant disease caused by a germline mutation in the adenomatous polyposis coli (APC) gene. Patients with FAP develop up to thousands of colorectal adenomas as well as lesions in the upper GI tract. In FAP, the upper digestive lesions include gastric fundic gland polyps (FGPs), antrum adenomas, duodenal or small intestinal adenomas, and carcinoma. Patients, after colectomy, are still at significant risk for extracolonic malignancies. Advances in endoscope resolution and optical enhancement technologies allow endoscopists to provide assessments of benign and malignant polyps. For this reason, in the past decades, endoscopic resection techniques have become the first line of treatment in patients with polyps in the upper GI, whereby polyps and even early cancers can be successfully cured. In FAP patients, endoscopic ampullectomy appears to be a safe and effective way of treating patients with ampullary tumors. According to current indications, endoscopic retrograde cholangiopancreatography (ERCP) and stenting of the main pancreatic duct follow ampullectomy.

Comparison of cold snare and hot snare polypectomy for the resection of sporadic nonampullary duodenal adenomas

BACKGROUND AND AIMS

Nonampullary duodenal adenomas can undergo malignant transformation, making endoscopic resection, often by hot snare (HSP) or cold snare polypectomy (CSP), necessary. Although CSP has been shown to be safer for removal of colon polyps, data comparing these techniques for the resection of duodenal adenomas are limited. Our aim was to compare the safety and efficacy of CSP and HSP for the removal of nonampullary duodenal adenomas.

METHODS

We performed a retrospective cohort study of patients referred to 2 academic medical centers with a histologically confirmed sporadic, nonampullary duodenal adenoma who underwent endoscopic snare polypectomy between January 1, 2007 and March 1, 2021. Patients with underlying polyposis syndromes were excluded. Outcomes included postprocedural adverse events and polyp recurrence.

RESULTS

Of 110 total patients, 69 underwent HSP and 41 underwent CSP. Intraprocedural bleeding was similar between both groups, but 7 patients in the HSP group experienced delayed adverse events versus none in the CSP group (P = .04). Fifty-four patients had complete polyp resection and subsequent surveillance endoscopies. Multivariate analysis showed polyp size to be associated with recurrence (per mm; odds ratio, 1.11; 95% confidence interval, 1.04-1.20; P < .01). Endoscopic resection technique (HSP vs CSP) was not a predictor of recurrence (P = .18).

CONCLUSIONS

HSP led to more delayed adverse events compared with CSP, whereas no significant differences on outcomes were noted, suggesting that CSP is equally effective and potentially safer for the removal of duodenal adenomas.