Is Cold Snare Piecemeal EMR Adequate in Treating Duodenal Adenomas?

Traditionally, nonampullary small-bowel adenomas ≥10 mm in diameter are resected utilizing cautery. Unfortunately, since the small bowel is thin-walled and highly vascular, adverse events are significant. Cold snare resection of polyps, initially performed in the colon, is now being adopted for small-bowel lesions. The aim of this retrospective study, performed at a tertiary care medical center, was to assess the safety and efficacy of cold snare EMR for removal of >10-mm adenomas from the small bowel.

From January 2014 through March 2019, 43 patients underwent lift and piecemeal cold snare EMR of small-bowel adenomas ≥1 cm in size. Of these patients, 39 had follow-up endoscopy and were included in the study. The size of the polyps ranged from 10 to 70 mm, with a mean size of 26.5 mm. 

Residual or recurrent adenoma was found in 18 patients (46%), with increased polyp size correlating with higher recurrence (P<.001). Polyp eradication was observed in 35 patients (89%), requiring a median of 2 (range 1-6) endoscopic procedures. One patient (2.3%) had immediate postprocedural bleeding followed by delayed bleeding at day 11 in the setting of an elevated international normalized ratio (warfarin) managed with clipping. No cases of perforation or postpolypectomy syndrome were seen. There was 1 case of necrotizing pancreatitis after the first surveillance endoscopy at which time the patient was treated with repeat resection and thermal therapy for residual adenoma. However, the patient eventually died.