Research Article|Articles in Press

Cold snare endoscopic mucosal resection for the removal of large duodenal adenomas

Published:January 27, 2023DOI:
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      Background and Aims

      Large (≥15mm) duodenal adenomas (DA) are premalignant and require removal. Existing endoscopic resection techniques are compromised by serious adverse events (SAE), most notably post procedural bleeding (PPB) and perforation. To ameliorate these problems we sought to evaluate the novel technique of cold snare endoscopic mucosal resection (CS-EMR) against the emerging standard of conventional EMR with thermal ablation of the post resection margin (EMR-T) for the safe and effective removal of DA.


      Consecutive patients were enrolled in a single tertiary centre for CS-EMR, and prospectively analyzed against a previously reported cohort of EMR-T from the same centre. The primary outcome was rate of SAE. Secondary outcomes were residual or recurrent adenoma (RRA) at first surveillance endoscopy (SE1) at 6 months and technical success per lesion.


      Between October 2019 and July 2022, 50 DA ≥15mm were removed via CS-EMR (median size 30mm [IQR 19mm – 40mm], mean age 70 years [SD 9.2 years]) compared with 54 DA via EMR-T (median size 30mm [IQR 19mm - 40mm], mean age 68 years [SD 12.2 years]). CS-EMR had a significantly lower rate of intraprocedural bleeding (2.0% vs 37%, P < .001) and PPB (4.0% vs 16.7%, P = .036). Two cases (4.0%) of immediate perforation occurred in CS-EMR. These were recognized immediately and closed with clips without sequelae. Total SAE (16.0% vs 16.7%, P = 1) and technical success (100% vs 100%, P = 1) were identical. Recurrence at SE1 was significantly higher in CS-EMR (24.4% vs 2.3%, P = .002).


      CS-EMR reduces IPB and PPB however it may increase the risk of immediate perforation and is associated with significantly higher rate of recurrence at SE1. Further technical refinements are required to optimize endoscopic resection techniques for DA.

      Key Words


      ASA (American Society of Anesthesiologists), CS-EMR (Cold snare endoscopic mucosal resection), DA (Duodenal Adenoma), DMI (Deep mural injury), EMR (Endoscopic mucosal resection), EMR-T (Endoscopic mucosal resection with thermal ablation of the post resection margin), HGD (High grade dysplasia), HR (Hazard ratio), IPB (Intraprocedural bleeding), IQR (Interquartile range), LGD (Lower grade dysplasia), PPB (Post procedural bleeding), RRA (Residual or recurrent adenoma), SAE (Serious adverse event), SD (Standard deviation), SE1 (First surveillance endoscopy), SMCI (submucosal invasive cancer), STSC (Snare tip soft coagulation), TA (Tubular adenoma), TVA (Tubulovillous adenoma)
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