Cold snare polypectomy for superficial non-ampullary duodenal epithelial tumor: a prospective clinical trial (pilot study)

Advances in Endoscopic Resection

This article provides an overview of recent advances in endoscopic resection techniques. It includes the brief overview of endoscopic submucosal dissection, regional differences in ESD indications, innovation of ESD techniques, and expansion to full-thickness resection. The article covers cold snare polypectomy for small polyps with tips, underwater endoscopic mucosal resection (U-EMR) for sessile lesions with tips and expanding role of U-EMR, and the key assistive techniques for ESD that have improved the safety and efficacy. Furthermore, it discusses the emerging field of endoscopic full-thickness resection including device-assisted and freehand exposure techniques.

A method of "Noninjecting Resection using Bipolar Soft coagulation mode; NIRBS" for superficial non-ampullary duodenal epithelial tumor: a pilot study

BACKGROUND

Complete endoscopic resection of superficial non-ampullary duodenal epithelial tumors (SNADETs) is technically difficult, especially with an extremely high risk of adverse event (AE), although various endoscopic resection methods including endoscopic mucosal resection (EMR), underwater EMR (UEMR), and endoscopic submucosal dissection (ESD) have been tried for SNADETs. Accordingly, a novel simple resection method that can completely resect tumors with a low risk of AEs should be developed.

AIMS

A resection method of Noninjecting Resection using Bipolar Soft coagulation mode (NIRBS) which has been reported to be effective and safe for colorectal lesions is adapted for SNADETs. In this study we evaluated its effectiveness, safety, and simplicity for SNADETs measuring ≤ 20 mm.

RESULTS

This study included 13 patients with resected lesions with a mean size of 7.8 (range: 3-15) mm. The pathological distributions of the lesions were as follows: adenomas, 77% (n = 10) and benign and non-adenomatous lesions, 23% (n = 3). The en bloc and R0 resection rate was 100% (n = 13). The median procedure duration was 68 s (32-105). None of the patients presented with major AEs including bleeding and perforation.

CONCLUSIONS

Large studies such as prospective, randomized, and controlled trials should be conducted for the purpose of validating effectiveness, safety, and simplicity of the NIRBS for SNADETs measuring ≤ 20 mm suggested in this study.

Initial Tumor Size and Narrow-Band Image Findings Estimate Growth Speed in Duodenal Tumors

INTRODUCTION

Recently, the detection of superficial non-ampullary duodenal epithelial tumors (SNADETs) including adenomas and superficial duodenal carcinomas has increased. Various endoscopic treatment methods have also been reported for SNADETs, but there are few reports on the natural history. The aim of this study was to analyze factors related to tumor growth and determine the characteristics of SNADETs which need early therapeutic intervention.

METHODS

A single-center, retrospective study was performed on the medical records of 309 patients with SNADETs who underwent endoscopic or surgical resection between January 2010 and May 2021. Of these, 41 patients who were followed up for more than 1 year by endoscopy were analyzed. The primary outcome was an analysis of the tumor growth speed. Secondary outcomes were the relationship between the tumor growth speed and mucin phenotype, tumor size and findings of magnifying endoscopy with narrow-band imaging (M-NBI).

RESULTS

The observation period was 24 months (13-182). Tumor growth speed was 1.1 mm/year (0-21.6). Tumor diameter ≥10 mm at first detection (p = 0.004; odds ratio 19.5 [2.03-186.96]) and mixed type by M-NBI (p = 0.036; odds ratio 9.69 [1.05-89.88]) were identified as risk factors of tumors growing at a rate of ≥3 mm/year. There was no statistically significant difference in the speed of tumor growth between the different mucin immunohistochemical phenotypes.

CONCLUSION

Initial tumor size and findings of M-NBI are useful to predict tumor growth and consider early intervention.

Safety of cold resection of non-ampullary duodenal polyps: Systematic review and meta-analysis

Background and study aims Endoscopic resection has traditionally involved electrosurgical cautery (hot snare) to resect premalignant polyps. Recent data have suggested superior safety of cold resection. We aimed to assess the safety of cold compared with traditional (hot) resection for non-ampullary duodenal polyps. Methods We performed a systematic review ending in September 2022. The primary outcome of interest was the adverse event (AE) rate for cold compared with hot polyp resection. We reported odds ratios with 95% confidence intervals (CIs). Secondary outcomes included rates of polyp recurrence and post-polypectomy syndrome. We assessed publication bias with the classic fail-safe test and used forest plots to report pooled effect estimates. We assessed heterogeneity using I 2 index. Results Our systematic review identified 1,215 unique citations. Eight of these met inclusion criteria, seven of which were published manuscripts and one of which was a recent meeting abstract. On random effect modeling, cold resection was associated with significantly lower odds of delayed bleeding compared with hot resection. The difference in the odds of perforation (odds ratio [OR] 0.31 [95% confidence interval [CI] 0.05-2.87], P =0.2, I 2 =0) and polyp recurrence (OR 0.75 [95% CI 0.15-3.73], P =0.72, I 2 =0) between hot and cold resection was not statistically significant. There were no cases of post-polypectomy syndrome reported with either hot or cold techniques. Conclusions Cold resection is associated with lower odds of delayed bleeding compared with hot resection for duodenal tumors. There was a trend toward higher odds of perforation and recurrence following hot resection, but this trend was not statistically significant.

Resectability of Small Duodenal Tumors: A Randomized Controlled Trial Comparing Underwater Endoscopic Mucosal Resection and Cold Snare Polypectomy

INTRODUCTION

Underwater endoscopic mucosal resection (UEMR) and cold snare polypectomy (CSP) are novel endoscopic procedures for superficial nonampullary duodenal epithelial tumors (SNADET). However, consensus on how to use both procedures appropriately has not been established. In this study, we evaluated treatment outcomes of both procedures, including resectability.

METHODS

In this single-center randomized controlled study conducted between January 2020 and June 2022, patients with SNADET ≤12 mm were randomly allocated to UEMR and CSP groups. The primary end point was sufficient vertical R0 resection (SVR0), which was defined as R0 resection including a sufficient submucosal layer. We compared treatment outcomes including SVR0 rate between groups.

RESULTS

The SVR0 rate was significantly higher in the UEMR group than in the CSP group (65.6% vs 41.5%, P = 0.01). By contrast, the R0 resection rate was not significantly different between study groups (70.3% vs 61.5%, P = 0.29). The submucosal layer thickness was significantly greater in the UEMR group than in the CSP group (median 546 [range, 309-833] μm vs 69 [0-295] μm, P < 0.01). CSP had a shorter total procedure time (median 12 [range, 8-16] min vs 1 [1-3] min, P < 0.01) and fewer total bleeding events (9.4% vs 1.5%, P = 0.06).

DISCUSSION

UEMR has superior vertical resectability compared with CSP, but CSP has a shorter procedure time and fewer bleeding events. Although CSP is preferable for most small SNADET, UEMR should be selected for lesions that cannot be definitively diagnosed as mucosal low-grade neoplasias.

Cold-snare endoscopic resection of non-ampullary duodenal adenomas: Systematic review and pooled-analysis

BACKGROUND

Mirroring the experience with colonic resections, cold snare-based techniques have been recently proposed for non-ampullary duodenal lesions to reduce the risk of adverse events (AEs). As the duodenal wall is thinner and more vascularized than in the colon, electrocautery-related AEs are relevant issues in this setting.

AIMS

We performed a systematic review with pooled-analysis to evaluate the efficacy and safety of this technique.

METHODS

Electronic databases (Medline, Scopus, EMBASE) were searched up to January 2023. Full articles including patients with duodenal lesions resected by cold-snare technique were eligible. The adverse events (i.e., bleeding, perforation, stricture), complete resection, and recurrence rates were pooled using a random model.

RESULTS

Eleven studies were eligible, providing data on 3137 lesions removed from 233 patients. The overall AE rate for cold snaring was 0.25% (95% CI, 0.19%-0.69%). Among the three studies comparing cold- and hot-snare approaches, procedure-related bleeding rate was significantly lower with cold approach (OR 1.21, 0.51-2.85; p = 0.66). The complete resection rate was 99.40% (95% CI, 98.60%-100%), with a residual/recurrence rate of 12.95% (95% CI, 4.75%-21.16%). On univariate meta-regression, lesion size significantly affected both the adverse events and recurrence risk.

CONCLUSION

Cold-snare resection appears effective and extremely safe for resecting non-ampullary duodenal lesions.

Gel immersion cold polypectomy with a duodenoscope for supra-ampullary adenoma

Watch a video of this article.

Cold snare resection for non-ampullary sporadic duodenal adenomas: systematic review and meta-analysis

Background and study aims The role of cold snare polypectomy (CSP) in curative resection of non-ampullary sporadic duodenal adenomas (NASDA) is debated. We conducted a systematic review and meta-analysis to investigate the efficacy and safety of CSP for NASDA. Patients and methods In this systematic review and meta-analysis, we identified published series of patients with CSP for NASDA by searching PubMed and Google Scholar, which resulted in six papers (205 lesions). The main outcome was the rate of local remission after repeated CSP, the secondary outcomes were rates of local remission at first control and rates for delayed bleeding and immediate perforations. We computed the weighted summary proportions under the fixed and random effects model. Results The pooled proportion of local remission after repeated CSP was 88% (95% confidence interval [CI] 57%-100%). The pooled proportion of local remission at first control was 81% (95% CI 55%-98%), the pooled proportion of delayed bleeding was 1% (95% CI 0%-4%) and the pooled proportion of immediate perforation was 0% (95% CI 0%-2%). Conclusions Our meta-analysis suggests that CSP should be considered as the first-line therapy for NASDA.

Salvage treatment for local recurrence after endoscopic resection for superficial nonampullary duodenal epithelial tumors

BACKGROUND AND AIMS

Local recurrence is a significant concern in endoscopic resection of superficial nonampullary duodenal tumors (SNADTs). Our objective was to elucidate the clinical outcomes of salvage endoscopic treatment.

METHODS

This retrospective study included consecutive patients who underwent endoscopic resection of SNADTs between January 2013 and December 2021. Four hundred thirty-three patients were observed, excluding those with familial adenomatous polyposis and those who did not undergo surveillance endoscopy. Local recurrence was defined as histologically proven adenoma or adenocarcinoma in contact with a prior endoscopic resection scar. The clinicopathological characteristics of patients with local recurrence and outcomes of salvage endoscopic treatment were evaluated.

RESULTS

Local recurrence occurred in 33 (8%) of the 433 patients after endoscopic resection for SNADT. Multivariate analysis identified older age (≥63 years), larger lesion size (≥13 mm), and piecemeal resection as significant independent predictors of local recurrence. Among the 33 patients with 33 recurrent lesions, 10 lesions (30%) disappeared after forceps biopsy. Three patients (9%) remained untreated. Sixteen lesions (48%) disappeared after one session of salvage endoscopic treatment, and four lesions (12%) disappeared after two sessions of treatment. Among these 24 treatment sessions, underwater endoscopic mucosal resection was performed in 19 sessions. The median post-procedural hospitalization period was four days (interquartile range, 3-4.25 days). Delayed bleeding occurred in three sessions. No recurrences have been detected in the 30 salvaged patients. The median recurrence-free survival time was 24.5 months (interquartile range, 14-48.75 months).

CONCLUSIONS

Local recurrence after endoscopic resection of SNADT can be managed endoscopically.

Superficial non-ampullary duodenal epithelial tumors now: endoscopic diagnosis and therapy

With the recent increase in the frequency of duodenal tumor detection, significant progress has been made in endoscopic diagnosis and treatment. Although the first guidelines were issued in Japan, patient treatment varies widely among institutions. There is a need for improving the quality of endoscopic diagnosis and more curative and safer treatments. Biopsy is the standard diagnostic method; however, the diagnostic accuracy of endoscopic biopsy is not so high. Therefore, the differentiation of superficial non-ampullary duodenal epithelial tumors from non-neoplastic lesions is being developed. The incidence of lymph node and distant metastases of duodenal epithelial tumors is extremely rare in intramucosal carcinomas, and they are considered good candidates for endoscopic treatment if the technical difficulties can be resolved. Adverse events associated with endoscopic treatment are greatly reduced at advanced facilities through novel resection and closure methods, and further improvements are expected in the future. Clarifying the risk of metastatic recurrence may lead to the development of more appropriate treatments and curative resection criteria.

Endoscopic resection of non-ampullary duodenal adenomas: Is cold snaring the promised land?

Due to the high risk of morbidity and mortality associated with surgical resection in this tract, endoscopic resection (ER) has taken the place of surgical resection as the first line treatment for non-ampullary duodenal adenomas. However, due to the anatomical characteristics of this area, which enhance the risk of post-ER problems, ER in the duodenum is particularly difficult. Due to a lack of data, no ER technique for superficial non-ampullary duodenal epithelial tumours (SNADETs) has yet been backed by strong, high-quality evidence; yet, traditional hot snare-based techniques are still regarded as the standard treatment. Despite having a favourable efficiency profile, adverse events during duodenal hot snare polypectomy (HSP) and hot endoscopic mucosal resection, such as delayed bleeding and perforation, have been reported to be frequent. These events are primarily caused by electrocautery-induced damage. Thus, ER techniques with a better safety profile are needed to overcome these shortcomings. Cold snare polypectomy, which has already been shown as a safer, equally effective procedure compared to HSP for treatment of small colorectal polyps, is being increasingly evaluated as a potential therapeutic option for non-ampullary duodenal adenomas. The aim of this review is to report and discuss the early outcomes of the first experiences with cold snaring for SNADETs.

Current status and perspectives for endoscopic diagnosis of superficial nonampullary duodenal epithelial tumors

In recent years, there have been significant advances in the endoscopic resection (ER) procedures of superficial nonampullary duodenal epithelial tumors (SNADETs). A preoperative endoscopic diagnosis is thus deemed necessary in determining the indication for subsequent ER. For the histologic and endoscopic diagnosis of SNADETs, understanding the mucin phenotype is inevitable. Recently, two diagnostic algorithms for the differential diagnosis of SNADETs from nonneoplastic lesions under magnifying endoscopy with narrow-band imaging have been proposed. In addition, various endoscopic approaches have been proposed to differentiate low- and high-grade adenomas/carcinomas, including white light endoscopy, magnifying image-enhanced endoscopy, and endocytoscopy. These methods, however, have not been standardized with respect to the classification of their findings and the validation of their diagnostic accuracy. Moreover, there are still concerns with respect to the histologic criteria required to establish a SNADETs diagnosis. Standardization in the histologic and endoscopic diagnosis of SNADETs is needed.

Outcomes of endoscopic mucosal resection for large superficial non-ampullary duodenal adenomas

Endoscopic mucosal resection (EMR) is the recommended treatment for superficial non-ampullary duodenal epithelial tumors larger than 6 mm. This endoscopic technique carries a high risk of adverse events. Our aim was to identify the risk factors for adverse events following EMR for non-ampullary duodenal adenomatous lesions. We retrospectively analyzed a prospectively collected database of consecutive endoscopic resections for duodenal lesions at a tertiary referral center for therapeutic endoscopy. We analyzed patients with non-ampullary duodenal adenomatous lesions ≥ 10 mm resected by EMR, and searched for factors associated with adverse events after EMR. 167 duodenal adenomatous lesions, with a median size of 25 (25–40) mm, were resected by EMR between January 2015 and December 2020. Adverse events occurred in 37/167 (22.2%) after endoscopic resection, with 29/167 (17.4%) delayed bleeding, 4/167 (2.4%) immediate perforation and 4/167 (2.4%) delayed perforation. In logistic regression, the size of the lesion was the only associated risk factor of adverse events (OR = 2.81, 95% CI [1.27; 6.47], p = 0.012). Adverse events increased mean hospitalization time (7.7 ± 9 vs. 1.9 ± 1 days, p < 0.01). None of the currently recommended preventive methods, particularly clips, affected the adverse event rate. EMR of centimetric and supracentimetric duodenal adenomatous lesions carries a high risk of adverse events, increasing with the size of the lesion and with no benefit from any preventive method. These results suggest that these procedures should be performed in expert centers, and underline the need for novel endoscopic tools to limit the rate of adverse events.