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

Open AccessPublished:May 23, 2022DOI:https://doi.org/10.1016/j.gie.2022.05.007

      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.

      Graphical abstract

      Abbreviations:

      APC (argon plasma coagulation), CSP (cold snare polypectomy), HSP (hot snare polypectomy)
      Sporadic nonampullary duodenal polyps are commonly found, with an incidence ranging from .3% to 5% of upper endoscopies.
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      Epidemiology of colorectal polyps.
      ,
      • Lim C.H.
      • Cho Y.S.
      Nonampullary duodenal adenoma: current understanding of its diagnosis, pathogenesis, and clinical management.
      Similar to colon adenomas, nonampullary duodenal adenomas can undergo malignant transformation, making endoscopic removal the standard for management.
      • Perzin K.H.
      • Bridge M.F.
      Adenomas of the small intestine: a clinicopathologic review of 51 cases and a study of their relationship to carcinoma.
      • Jepsen J.M.
      • Persson M.
      • Jakobsen N.O.
      • et al.
      Prospective study of prevalence and endoscopic and histopathologic characteristics of duodenal polyps in patients submitted to upper endoscopy.
      • Chathadi K.V.
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      • Acosta R.D.
      • et al.
      The role of endoscopy in ampullary and duodenal adenomas.
      Two major techniques for the endoscopic resection of polyps are hot snare polypectomy (HSP), which involves electrocautery, and cold snare polypectomy (CSP).
      Until recently, HSP had been the preferred method for removal of colon polyps because of the belief that electrocautery would prevent immediate bleeding while assisting in eradicating residual polyp tissue at the base.
      • Ket S.N.
      • Mangira D.
      • Ng A.
      • et al.
      Complications of cold.
      Despite the attempts to minimize immediate bleeding, HSP can lead to several clinically significant adverse events, including delayed bleeding, perforation, and cautery-related injury (postpolypectomy syndrome). Recently, CSP has grown in popularity because of studies demonstrating similar efficacy and lower postpolypectomy adverse events compared with HSP in resection of colon polyps ≤15 mm.
      • Repici A.
      • Hassan C.
      • Vitetta E.
      • et al.
      Safety of cold polypectomy for <10 mm polyps at colonoscopy: a prospective multicenter study.
      • Kawamura T.
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      • et al.
      A comparison of the resection rate for cold and hot snare polypectomy for 4-9 mm colorectal polyps: a multicentre randomised controlled trial (CRESCENT study).
      • Rex D.K.
      • Anderson J.C.
      • Pohl H.
      • et al.
      Cold versus hot snare resection with or without submucosal injection of 6-15 mm colorectal polyps: a randomized controlled trial.
      Although growing evidence shows the benefits of CSP in the resection of colon polyps, data comparing resection techniques for duodenal adenomas are limited. This is evident in the European Society of Gastrointestinal Endoscopy’s recent recommendations that although CSP can be used for duodenal polyps less than 6 mm, it is considered to be a weak recommendation based on little evidence from prior studies.
      • Vanbiervliet G.
      • Moss A.
      • Arvanitakis M.
      • et al.
      Endoscopic management of superficial nonampullary duodenal tumors: European Society of Gastrointestinal Endoscopy (ESGE) guideline.
      Although HSP has typically been used in the resection of nonampullary duodenal adenomas, a few small studies have shown that CSP can be performed safely as well. Both Maruoka et al
      • Maruoka D.
      • Matsumura T.
      • Kasamatsu S.
      • et al.
      Cold polypectomy for duodenal adenomas: a prospective clinical trial.
      and Hameda et al
      • Hameda K.
      • Takeuchi Y.
      • Ishikawa H.
      • et al.
      Feasibility of cold snare polypectomy for multiple duodenal adenomas in patients with familial adenomatous polyposis: a pilot study.
      conducted prospective trials that established CSP as a safe alternative to HSP for duodenal adenomas. However, no study has directly compared the 2 methods in terms of their safety and efficacy for polyp removal. The aim of this study was to compare the safety and efficacy of CSP and HSP for the resection of sporadic, nonampullary duodenal adenomas.

      Methods

      Our study base consisted of adult patients (age ≥18 years) from the University of California San Diego Medical Center and Veterans Affairs Hospital San Diego who underwent upper endoscopy with snare polypectomy of a nonampullary duodenal adenoma from January 1, 2007 to March 1, 2021. Patients who underwent alternative methods of polyp removal and those with underlying genetic conditions predisposing them to duodenal polyps (eg, familial adenomatous polyposis syndrome) were excluded. Institutional review board approval was obtained through the University of California San Diego Human Research Protections Program before data gathering.
      Subjects were identified using International Classification of Diseases, Tenth Revision codes D13.2 and D13.3 and search of pathology database records for duodenal adenoma. Manual chart review was performed for all patients to confirm the diagnosis of duodenal adenoma; to ascertain patient-related factors, including age, sex, and antithrombotic use, and polyp-related features, such as size, location, presence of high-grade dysplasia, experience level of the endoscopist, resection technique, and complete polyp resection; and to determine patient follow-up for postprocedural follow-up, polyp recurrence, and adverse events.
      Duodenal location was defined by segments including D1, D2, and D3. D1 was defined as the duodenal end of the pylorus to the superior duodenal flexure, D2 as the superior duodenal flexure to inferior duodenal flexure, and D3 as the inferior duodenal flexure to approximately where the duodenum crosses the vertebral column. Complete polyp resection was defined as visual confirmation of polyp resection made by the performing endoscopist. Postprocedural follow-up was defined as telephone call, patient messages in the electronic medical record, and office visits with GI or primary care within 30 days of the endoscopy. Delayed adverse events were defined as bleeding or perforation that occurred more than 1 day after polypectomy that necessitated clinic visit, emergency department visit, or hospitalization.
      Procedures were performed by 7 endoscopists, 6 of whom were trained in advanced endoscopy and 1 who was a general gastroenterologist. In our cohort, advanced endoscopists performed most procedures (102/110). Examples of polypectomy technique are shown in Figure 1; Figure 1A to C shows a polyp lifted and excised by HSP with the application of clips after polypectomy, whereas Figure 1D to F shows a polyp lifted and excised by CSP with argon plasma coagulation (APC) ablation of margins.
      Figure thumbnail gr1
      Figure 1A-C, A 20-mm D2 polyp lifted and excised using hot snare polypectomy with application of 4 clips postpolypectomy. D-F, A 25-mm D2 polyp lifted and excised using cold snare polypectomy with argon plasma coagulation ablation of margins postpolypectomy.

      Statistical analysis

      Continuous variables were evaluated for normality by using the Shapiro-Wilk test, were described as medians and interquartile ranges, and were compared using the Mann-Whitney U test. Categorical variables are described as counts and percentages and were compared using the Fisher exact test. Both univariate and multivariate logistic regression were performed to identify predictors of duodenal polyp recurrence. For multivariate analysis, backward stepwise elimination was done using a threshold of P < .15 for inclusion in the final model. Statistics were performed using IBM SPSS for Mac (version 25.0; Armonk, NY, USA).

      Results

      Among the 110 patients identified in our study cohort, 120 adenomatous duodenal polyps ≥5 mm were resected between January 1, 2007 and March 1, 2021, with 74 polyps (61.7%) undergoing HSP and 46 polyps (38.3%) undergoing CSP (Table 1). There was no difference in median age (68 years vs 72 years, P = .39), sex (49.3% male vs 68.3% male, P = .07), or antithrombotic use (13.0% vs 12.2%, P = 1.00) between patients who underwent HSP versus CSP, respectively. Median polyp size (15 mm vs 12 mm, P = .27), polyp location, histology, and en-bloc resection rates were similar between both groups. Submucosal lift (66.2% vs 37.0%, P < .01) and clips (55.4% vs 30.4%, P < .01) were used more frequently in polyps resected with HSP compared with CSP. APC was the only technique used after resection ablation in this cohort, with no difference in APC use (24.3% vs 19.6%, P = .54) between the 2 groups. Among the 27 instances where APC was used, in 12 cases APC was used to ablate the margins of the polypectomy site, and in 15 cases APC was used to ablate residual tissue at the polypectomy site. Chronologically, the first CSP resection took place in 2012, with all prior resections being done by HSP (Supplementary Fig. 1, available online at www.giejournal.org). Over the time period of our study, rates of CSP use increased.
      Table 1Patient, procedural, and polyp characteristics of duodenal polyp cohort
      Hot snare polypectomy (n = 69)Cold snare polypectomy (n = 41)P value
      No. of polyps74 (61.7)46 (38.3)
      Median age, y (interquartile range)68 (58.5, 76.0)72 (62, 76.5).39
      Male sex34 (49.3)28 (68.3).07
      Antithrombotic use9 (13.0)5 (12.2)1
      Antiplatelet (not aspirin)11
      Warfarin51
      Direct oral anticoagulant12
      Low-molecular-weight heparin20
      Direct thrombin inhibitor01
      Intraprocedural bleeding7 (10.1)4 (9.6)1
      Delayed adverse events7 (10.1)0.04
      Bleeding60
      Conservative management10
      Requiring transfusion, hospitalization, or further endoscopic intervention50
      Perforation10
      Median polyp size, mm (interquartile range)15 (10, 20)12 (5, 20).27
      Location in duodenum.21
      D114 (18.9)14 (30.4)
      D243 (58.1)26 (56.5)
      D317 (23.0)6 (13.0)
      Histology.38
      Adenoma/low-grade dysplasia61 (82.4)42 (91.3)
      High-grade dysplasia5 (6.8)2 (4.3)
      Villous/serrated8 (10.8)2 (4.3)
      Resection type.33
      Piecemeal39 (52.7)24 (52.2)
      En bloc35 (47.3)22 (47.8)
      Submucosal lift used49 (66.2)17 (37.0)<.01
      Clips used41 (55.4)14 (30.4)<.01
      Argon plasma coagulation used18 (24.3)9 (19.6).54
      Advanced endoscopist65 (94.2)37 (90.2).47
      Values are n or n (%) unless otherwise defined.
      There was no difference in intraprocedural bleeding between the HSP and CSP groups (10.1% vs 9.6%, P = 1.00). However, patients who underwent HSP had increased rates of delayed adverse events (10.1% vs 0%, P = .04). Of the 7 patients who experienced delayed adverse events, 6 had delayed bleeding (4 requiring hospitalization, blood transfusions, or repeat endoscopic evaluation and 2 managed conservatively), and 1 patient developed duodenal perforation requiring surgical repair (Table 2). The patient who experienced a perforation underwent HSP resection of a 15-mm polyp located in D2, which was followed by APC ablation of residual polyp and deployment of 3 clips. Lifting was not done in that patient, and the advanced endoscopist performing the case had over 20 years of experience. The patient presented to the emergency department the same day as his endoscopy; he underwent laparoscopic repair of his defect and recovered well.
      Table 2Description of patients with delayed adverse events
      Patient no.Days after EGDAdverse eventIntervention
      12BleedingClinic visit, conservative management
      21BleedingHospitalization, transfused 1 unit PRBC
      311BleedingHospitalization, transfused 5 units PRBCs, EGD with clip
      41PerforationHospitalization, surgical repair of perforation
      51BleedingEmergency department visit, conservative management
      62BleedingHospitalization, EGD with clip
      712BleedingHospitalization, transfused 2 units PRBCs, EGD with clip
      PRBC, Packed red blood cell.
      On review of patients with delayed adverse events, we found median polyp size was significantly larger in the delayed adverse event group (20 mm vs 15 mm, P = .03), and HSP was performed more frequently in the delayed adverse event group (100% vs 60.2%, P = .04) (Table 2). Clipping and APC were shown to trend toward being associated with delayed adverse events (P = .06 for both) as well. Given the lack of CSP outcomes in the delayed adverse event group, regression analysis for predictors of delayed adverse events could not be performed.
      Of our cohort of 110 patients, 102 (92.7%) had procedures that were done by advanced endoscopists with experience ranging from 3 to 20 years, whereas 8 (7.3%) had procedures done by a general gastroenterologist with 15 years of experience. All instances of delayed adverse events and 13 of 14 instances of recurrence occurred among procedures done by advanced endoscopists. Univariate analysis showed no significant difference in rates of delayed adverse events (P = 1.00) or recurrences (P = 1.00) between the 2 groups.
      Of the 110 patients who underwent snare polypectomy of a sporadic nonampullary duodenal adenoma, 104 (94.5%) had some form of postprocedural follow-up with our GI department or their primary care provider. Fifty-four (49.1%) underwent complete polyp resection and had surveillance endoscopy records available for review, whereas 56 patients were excluded from recurrence analysis (Supplementary Fig. 2, available online at www.giejournal.org). Median follow-up time for first surveillance EGD was 174.0 days (interquartile range, 91, 269.75). Figure 2 depicts the breakdown of recurrence and remission between the 2 groups. At the time of first surveillance endoscopy, 74.1% of patients had no evidence of residual/recurrent adenoma; 80% in the HSP group and 63.2% in the CSP group (P = .18). Among the 14 patients (25.9%) with adenoma recurrence, a median number of 1.5 (interquartile range, 1, 3) surveillance endoscopies were performed with eventual adenoma remission occurring in 6.
      Figure thumbnail gr2
      Figure 2Flowchart breakdown of patients who had polyp recurrence or remission after either hot or cold snare polypectomy.
      Among the 54 patients with endoscopic surveillance, 91.4% of patients in the HSP group achieved eventual successful eradication of duodenal adenomas compared with 73.7% in the CSP group by the end of the study period (P = .08). Of the 8 patients with residual duodenal adenomas, 3 were in the HSP group and 5 in the CSP group. Two patients in the CSP group were actively undergoing surveillance at the time of our study’s conclusion (Supplementary Table 1, available online at www.giejournal.org). Three patients had microscopic adenomatous tissue on biopsy samples only, and 5 patients had endoscopically visible residual adenoma (all <6 mm). These patients may have had eventual remission of duodenal adenomas, but further endoscopies were not performed at our institution.
      Univariate analysis of predictors of polyp recurrence showed increasing polyp size (per mm; odds ratio, 1.10; 95% confidence interval, 1.03-1.18; P < .01) and high-grade dysplasia compared with low-grade dysplasia (odds ratio, 16.0; 95% confidence interval, 1.59-161.17; P = .02) as the only statistically significant variables associated with duodenal adenoma recurrence (Table 3). On multivariate analysis, only polyp size was associated with an increased risk of recurrence (per mm; odds ratio, 1.11; 95% confidence interval, 1.04-1.20; P < .01). Resection technique (CSP vs HSP) was not associated with duodenal adenoma recurrence on univariate or multivariate analysis.
      Table 3Univariate analysis of predictors of duodenal adenoma recurrence
      CovariateOdds ratio (95% confidence interval)P value
      Age.98 (.92-1.03).41
      Sex (F vs M)1.35 (.40-4.59).63
      Technique (cold snare polypectomy vs hot snare polypectomy)2.33 (.67-8.12).18
      No. of polyps excised (multiple vs 1)3.00 (.18-51.45).45
      Anticoagulation (yes vs no).69 (.07-6.78).75
      Intraprocedural bleeding (yes vs no).44 (.05-3.98).46
      Portion of duodenum
      D2 vs D1.74 (.12-4.57).75
      D3 vs D11.25 (.16-9.54).83
      Histology
      High-grade dysplasia vs low-grade dysplasia16.0 (1.59-161.17).02
      Villous/serrated adenoma vs low-grade dysplasia1.33 (.12-14.38).81
      Resection type (piecemeal vs en bloc)2.20 (.52-9.18).28
      Submucosal lift (yes vs no).73 (.18-2.88).65
      Clips (yes vs no)1.35 (.36-5.09).66
      Argon plasma coagulation (yes vs no)1.03 (.29-3.68).96
      Polyp size, mm1.10 (1.03-1.18)<.01
      Advanced endoscopist vs general GI.68 (.05-8.18).76
      Table 4Comparison of patients with and without delayed adverse events after endoscopic snare resection of duodenal adenomas
      Delayed adverse events (n = 7)No delayed adverse events (n = 103)P value
      Median polyp size, mm (interquartile range)20 (15, 30)15 (10, 20).03
      Hot snare polypectomy7 (100)62 (60.2).04
      Submucosal lift used5 (71.4)60 (58.3).7
      Clips used6 (85.7)48 (46.6).06
      Argon plasma coagulation used4 (57.1)23 (22.3).06
      Resection type
      Piecemeal6 (85.7)56 (54.4).13
      En bloc1 (14.3)47 (45.6)
      Values are n (%) unless otherwise defined.

      Discussion

      In this retrospective cohort study of 110 patients who underwent endoscopic resection of duodenal adenomas, we found an increased risk of delayed adverse events (bleeding, perforation) among patients who underwent HSP compared with CSP. Efficacy was similar between the 2 techniques with no significant difference in adenoma recurrence risk.
      HSP and CSP techniques have been compared in multiple studies examining resection of colon polyps. Our finding of increased delayed adverse events with HSP in duodenal polyp resection is consistent with studies demonstrating increased risk of bleeding and perforation in colon polyp resection when using HSP.
      • Horiuchi A.
      • Nakayama Y.
      • Kajiyama M.
      • et al.
      Removal of small colorectal polyps in anticoagulated patients: a prospective randomized comparison of cold snare and conventional polypectomy.
      ,
      • Jegadeesan R.
      • Aziz M.
      • Desai M.
      • et al.
      Hot snare vs. cold snare polypectomy for endoscopic removal of 4 - 10 mm colorectal polyps during colonoscopy: a systematic review and meta-analysis of randomized controlled studies.
      The proposed mechanism for increased risk of delayed adverse events is because of thermal damage to the duodenal wall, leading to an increased risk of perforation and eschar formation, which can result in delayed bleeding. In our study, the rate of delayed adverse events with HSP was 10.1%, whereas our adverse event rate overall was 6.4%, significantly higher than the .6% to 2% described in colon polyps but on par with the 4% to 16% described in resection of duodenal lesions.
      • Sorbi D.
      • Norton I.
      • Conio M.
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      Postpolypectomy lower GI bleeding: descriptive analysis.
      • Park S.K.
      • Lee M.G.
      • Jeong S.H.
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      Prospective analysis of minor adverse events after colon polypectomy.
      • Sohn J.W.
      • Jeon S.W.
      • Cho C.M.
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      Endoscopic resection of duodenal neoplasms: a single-center study.
      • Lépilliez V.
      • Chemaly M.
      • Ponchon T.
      • et al.
      Endoscopic resection of sporadic duodenal adenomas: an efficient technique with a substantial risk of delayed bleeding.
      • Alexander S.
      • Bourke M.J.
      • Williams S.J.
      • et al.
      EMR of large, sessile, sporadic nonampullary duodenal adenomas: technical aspects and long-term outcome (with videos).
      The difference between duodenal and colonic adverse event rates can be explained by the thinner and more vascular duodenal wall, which makes polypectomy in this region more prone to adverse events than other regions of the GI tract.
      • Latos W.
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      Along with technique, we found median polyp size to be associated with delayed adverse events, with larger polyp sizes significantly associated with delayed adverse events. This is a finding similar to prior studies that have demonstrated increased postpolypectomy bleeding, both immediate and delayed, to be associated with increasing polyp size.
      • Valli P.V.
      • Mertens J.C.
      • Sonnenberg A.
      • et al.
      Nonampullary duodenal adenomas rarely recur after complete endoscopic resection: a Swiss experience including a literature review.
      ,
      • Jaruvongvanich V.
      • Prasitlumkum N.
      • Assavapongpaiboon B.
      • et al.
      Risk factors for delayed colonic post-polypectomy bleeding: a systematic review and meta-analysis.
      Breaking our adverse event rates down further, we saw a 5.5% incidence of delayed bleeding and a 1% incidence of perforation. Tsutsumi et al’s
      • Tsutsumi K.
      • Kato M.
      • Kakushima N.
      • et al.
      Efficacy of endoscopic preventive procedures to reduce delayed adverse events after endoscopic resection of superficial nonampullary duodenal epithelial tumors: a meta-analysis of observational comparative trials.
      meta-analysis on delayed adverse events after resection of duodenal adenomas noted similar rates for both types of adverse events, with studies showing a 3.5% to 15.8% incidence for delayed bleeding and a 0% to 3.9% incidence rate for perforation.
      To our knowledge, this is the first study to compare both HSP and CSP in the resection of duodenal polyps. The incidence of duodenal adenomas is much lower than colon polyps, which may explain the dearth of studies regarding duodenal polyp resection techniques.
      • Ma M.X.
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      Management of duodenal polyps.
      Maruoka et al
      • Maruoka D.
      • Matsumura T.
      • Kasamatsu S.
      • et al.
      Cold polypectomy for duodenal adenomas: a prospective clinical trial.
      and Hameda et al
      • Hameda K.
      • Takeuchi Y.
      • Ishikawa H.
      • et al.
      Feasibility of cold snare polypectomy for multiple duodenal adenomas in patients with familial adenomatous polyposis: a pilot study.
      conducted some of the earliest studies for CSP for duodenal adenomas in 2016 and 2017, demonstrating it to be a safe and effective method. Maruoka et al examined outcomes among 30 diminutive nonampullary sporadic duodenal adenomas (<6 mm) that were resected with CSP and found no delayed adverse events (bleeding, perforation) or adenoma recurrence. Although the most recent endoscopic guidelines still limit official recommendations for CSP to polyps ≤6 mm, studies now suggest polyps ≥10 mm can be safely removed by CSP as well. Choksi et al
      • Choksi N.
      • Elmunzer B.J.
      • Stidham R.W.
      • et al.
      Cold snare piecemeal resection of colonic and duodenal polyps ≥1 cm.
      examined 15 patients who underwent CSP of duodenal polyps >1 cm (mean size, 24 mm) and demonstrated that CSP was safe, with only 1 hospitalization for postprocedural bleeding in a patient on warfarin. Dang et al
      • Dang D.T.
      • Suresh S.
      • Vance R.B.
      • et al.
      Outcomes of cold snare piecemeal EMR for nonampullary small-bowel adenomas larger than 1 cm: a retrospective study.
      found that among their cohort of 43 patients with ≥10-mm duodenal adenomas, piecemeal CSP led to an eradication rate of 89% and only 1 episode of postprocedural bleeding.
      In terms of efficacy, 74.1% of patients had remission at the time of first follow-up, and 83.3% had remission after multiple endoscopies. We found no significant difference in rates of polyp recurrence between the HSP and CSP groups. When comparing our results with existing studies, we found that our rates of efficacy fall within previously described ranges. For example, Sohn et al
      • Sohn J.W.
      • Jeon S.W.
      • Cho C.M.
      • et al.
      Endoscopic resection of duodenal neoplasms: a single-center study.
      demonstrated a recurrence rate of 8.7% in their retrospective study of 24 patients who underwent EMR for duodenal adenomas, whereas Tomizawa and Ginsberg
      • Tomizawa Y.
      • Ginsberg G.G.
      Clinical outcome of EMR of sporadic, nonampullary, duodenal adenomas: a 10-year retrospective.
      showed a recurrence rate of 23% when looking at their cohort of 162 patients who underwent the same procedure. Increasing duodenal polyp size was associated with an increased risk of recurrence on multivariate analysis, a finding seen in prior studies of colon polyps.
      • Harrington L.
      Application of machine learning on colonoscopy screening records for predicting colorectal polyp recurrence.
      ,
      • Zhan T.
      • Hielscher T.
      • Hahn F.
      • et al.
      Risk factors for local recurrence of large, flat colorectal polyps after endoscopic mucosal resection.
      In our study, for every 1-mm increase in polyp size, the risk of recurrence was increased by 15%. Although only 6 of 14 patients with polyp recurrence eventually achieved remission, all patients experienced decreases in polyp size. Of the 8 patients with continued recurrence, 3 had only microscopic adenomatous tissue detectable and the other 5 had sub-10-mm residual polyps. Although a higher proportion of patients in the HSP group underwent eventual eradication of their polyps, some of this difference may be explained by several patients in the CSP group who were actively undergoing polyp surveillance at the time of our study’s conclusion.
      It should be noted that although our study focused on snare polypectomy for sporadic nonampullary duodenal lesions, other methods for polyp removal have demonstrated safety and efficacy as well. In particular, underwater EMR and cap-assisted EMR both demonstrate good efficacy and safety and may be the preferred method of resection at certain institutions.
      • Okimoto K.
      • Maruoka D.
      • Matsumura T.
      • et al.
      Appropriate selection of endoscopic resection for superficial nonampullary duodenal adenomas in association with recurrence.
      This highlights the still-unanswered question of which method of polyp removal is optimal for these polyps, a question that may only be answered by future randomized controlled trials.
      • Lim C.H.
      • Cho Y.S.
      Nonampullary duodenal adenoma: current understanding of its diagnosis, pathogenesis, and clinical management.
      Several limitations may be considered in interpreting our findings. First, this is a retrospective study with inherent limitations such as a reliance on previously collected data that did not include certain types of information such as electrosurgical generator settings or types of cold snare used. Second, our data spanned 14 years, and we were not able to control for changes in technology or technique that may have impacted adverse events and recurrence rates. In particular, we noted a chronologic difference in technique used, with significantly more instances of HSP used early in our study period. This in part is because of the more recent popularization of CSP, and we note our first case in 2012. Although this is a limitation we were unable to manage, there were no significant differences in the baseline characteristics between the CSP and HSP groups. Third, of the 110 patients we identified, only 54 had repeat surveillance endoscopies at our facilities, limiting our assessment of efficacy. Fourth, with only 7 instances of delayed adverse events, our statistical analyses on this outcome were limited, and we may not have had adequate power to assess for all significant associations. Despite these limitations, our study represents one of the largest cohorts of duodenal adenomas and, to our knowledge, the only study comparing CSP and HSP resection of duodenal adenomas.
      In conclusion, our study demonstrates that CSP has fewer delayed adverse events compared with HSP and is equally efficacious for the resection of sporadic, nonampullary duodenal adenomas. Although larger prospective trials are needed to compare the safety and efficacy of CSP and HSP for the resection of duodenal adenomas, our study suggests that CSP should be more widely considered for the resection of duodenal adenomas.

      Appendix

      Figure thumbnail fx2
      Supplementary Figure 1Distribution of hot and cold snare polypectomies across study period. HSP, Hot snare polypectomy; CSP, cold snare polypectomy.
      Figure thumbnail fx3
      Supplementary Figure 2Flowchart depicting reasons for exclusion of 56 patients from recurrence analysis.
      Supplementary Table 1Characteristics of patients with residual adenomas
      Patient no.Date of index EGDOriginal polyp size (mm)Technique usedNo. of subsequent endoscopiesDate of most recent surveillanceMost recent surveillance finding
      14/23/1635HSP12/28/175-mm adenoma
      27/10/134-8 mm × 4CSP17/13/15Diminutive adenoma
      34/30/1820CSP21/28/21Focal microscopic adenoma
      42/11/2030CSP110/6/206-mm adenoma
      57/23/0830HSP15/5/09Microscopic adenoma
      63/26/1340HSP110/1/13Microscopic adenoma
      75/23/1250CSP11/16/13Microscopic adenoma
      82/26/1812CSP12/26/184-mm adenoma
      HSP, Hot snare polypectomy; CSP, cold snare polypectomy.

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