Cold snare polypectomy in the management of duodenal adenoma in familial adenomatous polyposis

Aims Duodenal adenomas are frequent manifestations in individuals affected by familial adenomatous polyposis (FAP), being present in 30–90% of FAP patients. Due to the specific risk of neoplastic transformation associated with duodenal adenomas, careful surveillance and management are essential. The Spigelman index (SI) score system, introduced in 1989, is utilized to predict the risk of duodenal cancer in FAP patients. Patients with a Spigelman score of IV face a higher risk of duodenal cancer and are advised to undergo pancreaticoduodenectomy. Endoscopic resection of duodenal adenoma can prevent the occurrence of duodenal cancer and recently the use of cold snare polypectomy has been proposed for the prevention of advanced duodenal lesions.

The aim of this study is to conduct a prospective evaluation of the safety and feasibility of cold snare polypectomy for the treatment of duodenal adenomas in patients with FAP.

Methods From September 2022 to October 2023, we prospectively enrolled all patients with FAP who underwent upper gastrointestinal endoscopy for the surveillance of gastric and duodenal lesions. The diagnosis of FAP was established based on genotyping information and/or clinical observations of colorectal polyposis. We aimed at identifying and removing all significant adenomatous duodenal lesions, defined as lesions exceeding 5 mm in diameter. For lesions ranging from 5 to 10 mm, we performed cold snare en-bloc polypectomy, while lesions exceeding 10 mm underwent cold snare piece-meal polypectomy. Upper GI endoscopies were conducted with conscious sedation or deep sedation as necessary. Follow-up endoscopy appointments were scheduled at 6-12 months based on the pathology report. Data on patient characteristics, lesion characteristics, details of endoscopic treatment, adverse events, pathologic findings, and Spigelman index (SI) were collected and evaluated

Results Overall, 230 upper gastrointestinal endoscopies were conducted in patients with FAP. Among these, 14 individuals (7 females, median age 53 years) had relevant duodenal involvement. All patients had previously undergone total colectomy. A total of 48 lesions were removed over 16 sessions of endoscopic resections. No significative adverse events were reported. Histology reports indicated low-grade tubular adenoma in 3 cases, low-grade tubular-villous adenoma in 7 cases, and high-grade tubular-villous adenoma in 5 cases. One patient, having a SI of IV at the index upper endoscopy had evidence of adenocarcinoma at histology and was referred for surgery. Follow-up endoscopy data were available for 33% of patients. Follow-up examination showed stable SI in all cases without evidence of advanced lesions or significant fibrosis.

Conclusions Cold snare resection proves to be a safe and feasible technique for the endoscopic management of duodenal adenomas in patients with FAP. Even if more extensive studies are necessary to delineate the role of cold snare polypectomy in FAP, it appears that repeated endoscopic treatments may play a role in enhancing disease control.

Publication History

Article published online:
15 April 2024