Cold-snare endoscopic mucosal resection of large duodenal laterally spreading tumors: is cold the future gold standard?

Large laterally spreading tumors (LSTs) of the duodenum are considered by most experts to be very challenging benign lesions requiring endoscopic resection. Piecemeal endoscopic mucosal resection (EMR) is the gold standard but leads to a high recurrence rate and a risk of delayed bleeding.

Piecemeal cold snare EMR [1] has recently been reported as a promising new tool for excising sessile serrated lesions with the same efficiency as classic piecemeal EMR but with a better safety profile, with no perforations and a significantly lower rate of delayed post-EMR bleeding. Here, we report the case of a large 4-cm LST of the duodenum treated with cold snare piecemeal EMR ([Fig. 1], [Fig. 2], [Fig. 3], [Video 1]).

Fig. 1 Large duodenal laterally spreading tumor.

Fig. 2 Piecemeal cold snare resection of the laterally spreading tumor.

Fig. 3 Prophylactic clip closure.

Video 1 Cold snare endoscopic mucosal resection of a large duodenal laterally spreading tumor.

Download Video

The tumor was resected with a classic hexagonal pure cold snare in a piecemeal fashion. Minor intraprocedural bleeding was tolerated with a regular waterjet wash. Complete macroscopic removal was possible in 15 minutes, and the scar was closed with large hemostatic clips. No postprocedural complications occurred and no residual adenomas were detected at the 6-month follow-up gastroscopy.

Cold snare piecemeal resection could become a new standard of care for large duodenal adenomas [2], as this technique decreased the high risk of complications in this location (perforation, delayed bleeding, or postpolypectomy syndrome). A prospective observational Italian study is ongoing to evaluate this procedure for large duodenal adenomas (NCT04783961).

Endoscopy_UCTN_Code_CPL_1AH_2AZ

• References

• 1 van Hattem WA, Shahidi N, Vosko S. et al. Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods. Gut 2021; 70: 1691-1697
• 2 Ochiai Y, Kato M, Kiguchi Y. et al. Current status and challenges of endoscopic treatments for duodenal tumors. Digestion 2019; 99: 21-26