ANCHORING THE SNARE TIP USING A SMALL INCISION IN THE SUBMUCOSA FACILITATES EN BLOC ENDOSCOPIC MUCOSAL RESECTION FOR SPORADIC DUODENAL ADENOMAS

Sporadic duodenal adenomas (SDA) are rare with an estimated prevalence of 0.31% à 4.6% of upper gastrocopy. Nowadays, endoscopic resection is the recommended treatment for SDA thanks to its low morbidity and mortality compared to surgical duodenopancreatectomy. The reference technique of endoscopic resection is endoscopic mucosal resection (EMR) with snare because of the high risk of perforation associated with endoscopic submucosal dissection (ESD) Nevertheless, EMR's rate of En Bloc resection with free margins is lower than ESD resulting in a higher risk of local recurrence. Thus, it is commonly accepted to use EMR despite of the lower rate of curative resection in order to reduce the perforation rate. As previously demonstrated in the colon, snare tip anchoring is effective to improve snare positionning and allows to increase the size of the resected area. Compared to standard EMR, this strategy could increase the rate of R0 resection.

We report here two cases of EMR for duodenal adenoma in the second part of the duodenum of two septuagenarian patients. After injection of saline solution in the submucosa, we anchored the tip of a 25 mm-snare at one side of the adenoma (figure 1, Video 1), using a little incision made with cutting current. Then, the snare spread around the lesion, kept on stability, and allowed resecting the lesion En Bloc. Finally, the lateral and in-depth resections were complete without adenomatous residual tissue.

Finally, anchoring the snare does not represent an overcost but seems effective and simple to improve the area catched during EMR to allow En Bloc resection with margins for the duodenal adenomas.