An 83-year-old woman was referred for the management of an incidentally found large
duodenal polyp. The polyp was biopsied by the referring physician and was found to
be a tubulovillous adenoma. The patient was scheduled for esophagogastroduodenoscopy
with endoscopic mucosal resection (EMR).
The procedure was performed under general anesthesia, using a therapeutic upper endoscope
and duodenoscope. A 6-cm polyp was visualized in the second part of the duodenum ([Fig. 1]), 1 cm proximal to the major papilla. The polyp involved 60 % of the luminal circumference.
No depressed or ulcerated areas were noted upon examination with high-definition white-light
and narrow-band imaging. The polyp was injected submucosally with a 1:200 000 solution
of epinephrine in saline and methylene blue ([Fig. 2]). Piecemeal cold snare EMR was performed using a 9-mm cold snare (Exacto; US Endoscopy,
Mentor, Ohio, USA). The total procedure time was 2 hours 30 minutes; an advanced endoscopy
fellow assisted with the procedure, resulting in a somewhat extended procedure time.
The entire polyp was removed ([Fig. 3]), and resected fragments were suctioned through the endoscope channel and retrieved
completely. Minimal self-limited oozing was noted from the resection site, but did
not require any treatment.
Fig. 1 Duodenal polyp. a, b The polyp was visualized in the second part of the duodenum.
Fig. 2 Submucosal injection of the polyp.
Fig. 3 The resection base after cold snare endoscopic mucosal resection.
The patient recovered well following the procedure, without any complications. Pathology
showed a tubulovillous adenoma without high grade dysplasia.
The patient returned for surveillance 3 months later. During surveillance endoscopy,
a 12-mm residual polyp was noted, which was resected using piecemeal cold snare resection,
with good results ([Fig. 4]).
Fig. 4 Surveillance endoscopy. a A residual polyp was found during surveillance. b The resection base after removal of the residual polyp
Video 1 Cold snare piecemeal endoscopic mucosal resection of large periampullary duodenal
adenoma.
This case demonstrates the successful use of a cold snare piecemeal EMR technique
for a large periampullary duodenal adenoma/polyp. This technique is well described
for large colon polyps where it has been found to have extremely low complication
rates [1]. In contrast, high complication rates have been reported for hot snare EMR of duodenal
polyps [2]. The cold snare technique could be considered preferentially for the resection of
large duodenal polyps in order to minimize complication rates.
Endoscopy_UCTN_Code_TTT_1AO_2AG
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
