Endoscopy 2019; 51(08): E217-E218
DOI: 10.1055/a-0875-3838
© Georg Thieme Verlag KG Stuttgart · New York

Cold snare piecemeal endoscopic mucosal resection of a very large duodenal adenoma

Siddharth B. Javia
Department of Internal Medicine, Division of Gastroenterology and Hepatology, Henry Ford Health Systems, Detroit, United States
Krishnavel Chathadi
Department of Internal Medicine, Division of Gastroenterology and Hepatology, Henry Ford Health Systems, Detroit, United States
› Author Affiliations
Further Information

Publication History

Publication Date:
30 April 2019 (online)

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.

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Fig. 1 Duodenal polyp. a, b The polyp was visualized in the second part of the duodenum.
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Fig. 2 Submucosal injection of the polyp. 
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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]).

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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.


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