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

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.

Fig. 1 Duodenal polyp. a, b The polyp was visualized in the second part of the duodenum.

Fig. 2 Submucosal injection of the polyp. 

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]).

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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• References

• 1 Piraka C, Saeed A, Waljee AK. et al. Cold snare polypectomy for non-pedunculated colon polyps greater than 1 cm. Endosc Int Open 2017; 5: E184
• 2 Pérez-Cuadrado-Robles E, Quénéhervé L, Margos W. et al. Comparative analysis of ESD versus EMR in a large European series of non-ampullary superficial duodenal tumors. Endosc Int Open 2018; 6: E1008-E1014