Diagnosis of SEL in the upper and lower GI tract with express unroofing using cold snare: an effective and safe one-stop-shop technique

Aims Rapid characterization of subepithelial lesions (SELs) helps to determine adequate management. Further unnecessary diagnostic work up, often including endoscopic procedures, can be avoided, if the exact diagnosis is made during index endoscopy. Our group published the so far largest serious of upper GI SEL express unroofing (EU) using cold snare, showing high efficacy and excellent safety (10.5946/ce.2023.091). We herein present results of continuous and systematic cold snare EU in the upper and lower GI tract.

Methods Since September 2022 the standard of procedure (SOP) in our institution in regard to SELs diagnostics demands cold snare EU with or without additional endoscopic ultrasonography (EUS). Biopsies were taken using a standard forceps after EU with a cold snare. If present, oral anticoagulants were paused according to the general polypectomy recommendations. Amongst others, location, final diagnosis, complications and the necessity for clipping were recorded.

Results A total of 52 patients (median age=76.5 years) with 56 SELs (mean size=13.5mm, range: 3-40mm) in the upper (n=34) and lower (n=22) GI tract were evaluated. Eight SELs (14%) were previously biopsied with inconclusive histology. Twenty-two patients (39%) underwent endoscopy before (range: 1-4) and n=15 were explicitly referred for further SEL diagnostic to our institution. However, most (68%) were coincidental findings in daily routine. Fifty-nine percent (20/34) of upper GI SELs were additionally examined with EUS. Following cold snare EU, a histological diagnosis was made in 71.4% (n=40), including n=4 gastrointestinal stroma tumors (GIST) and n=6 ectopic pancreas, most (n=34) were lipomas. The remaining (n=16) were diagnosed with typical EUS and/or macroscopic appearance (n=12), after full-thickness resection (n=1) and surgical resection (n=1); n=2 remained unclear. No intra- or postprocedural bleeding occurred. In n=8 (14%) prophylactic clips were applied. The majority (86%) required no further surveillance. No relevant complication occurred.

Conclusions Cold snare EU is effective, safe, eliminates the need for electrocautery and potentially offers the possibility of final histologic diagnosis during outpatient index endoscopy without additional EUS, hindering further unnecessary surveillance.

Publication History

Article published online:
27 March 2025