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ABSTRACT
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.
Methods
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.
Results
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).
Conclusion
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
Acronyms:
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)To read this article in full you will need to make a payment
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Article info
Publication history
Accepted:
January 23,
2023
Received in revised form:
December 15,
2022
Received:
October 18,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
Conflicts of interest:
Michael J. Bourke: Research Support: Olympus, Cook Medical, Boston Scientific.
The remaining authors have no conflicts of interest to disclose.
Funding statement:
The Cancer Institute of New South Wales provided funding for a research nurse and data manager to assist with the administration of the study.
Authorship statement:
Hunter Wang: Study design, collected, organised and analysed data, performed statistical analyses, wrote and revised the manuscript after review by the co-authors
Mayenaaz Sidhu: analysed data, reviewed manuscript
Sunil Gupta, Oliver Cronin, Tim O’Sullivan, Anthony Whitfield, Nicholas G. Burgess: Identified and recruited patients, performed procedures
Michael J. Bourke: Conceived, initiated and designed the study. Critically reviewed and approved the final manuscript.
Identification
Copyright
© 2023 by the American Society for Gastrointestinal Endoscopy
