Introduction
Cold snare polypectomy (CSP) and underwater endoscopic mucosal resection (UEMR) represent relatively novel techniques for the management of superficial non-ampullary duodenal epithelial tumors. While CSP has been demonstrated to be safe and efficacious in a large-scale clinical trial for non-ampullary duodenal adenomas (NADAs) with a diameter of less than 10 mm [1], UEMR has been shown to be safe and effective in a prospective clinical trial for NADAs with a diameter of less than 20 mm [2]. However, there is no consensus on which technique should be used for NADAs 10 mm or less.
Aims & Methods
This study aimed to evaluate the treatment outcomes of CSP and UEMR for NADAs 10 mm or less. Patients who underwent CSP or UEMR for NADAs 10 mm or less at our institution between January 2015 and December 2022 were included, excluding FAP and local recurrence cases. Adenomas were defined as either Vienna classification category 3 on preoperative biopsy or endoscopically diagnosed as adenomas. The decision to perform either CSP or UEMR, as well as mucosal closure at the ulcer base after resection, was left to the discretion of the endoscopist. Procedure time was measured from snare visibility on the monitor until the end of resection for CSP, and from the beginning of water immersion until the end of resection for UEMR. The resected specimens were pinned to the corkboard and submitted to the pathology department. Follow-up endoscopy was conducted 2–3 months after endoscopic treatment to confirm the presence or absence of residual lesions, followed by an annual endoscopic examination.
Results
A total of 51 lesions were treated using CSP, while 29 lesions were treated with UEMR. The location of the lesions was distributed as follows: 9.8%, 84.3%, and 5.9% for the first, second, and third regions in the CSP group; and 13.8%, 82.5%, and 6.3% in the UEMR group (p=0.84). The difference in lesion diameter between the CSP and UEMR groups was not statistically significant (6.3±2.5 mm and 7.3±2.2 mm, respectively; p=0.06). Preoperative biopsy was performed in 43.1% of the CSP group and 58.6% of the UEMR group (p=0.18). The mean procedure time for CSP and UEMR was 4.6±4.2 min and 6.1±6.9 min, respectively (p=0.29). Mucosal closure at the ulcer base was performed in 56.9% of the CSP group and 100% of the UEMR group (p<0.01). Neither group experienced intraoperative perforation, postoperative bleeding, or delayed perforation (95% CI: 0–7.0% for the CSP group, 0–11.9% for the UEMR group). The en-bloc resection rates were 96.8% for CSP and 100% for UEMR (p=0.17), and the electric current application rate for CSP was 7.8%. The final pathological diagnosis in the CSP group was 82.4% adenoma, 3.9% intramucosal adenocarcinoma, and 13.7% non-neoplasm, while in the UEMR group, it was 89.7% adenoma, 10.3% intramucosal adenocarcinoma, and 0% non-neoplasm (p=0.02). The lateral and vertical margin-negative rates were 62.8% and 94.1% in the CSP group, and 62.1% and 100% in the UEMR group, respectively (p=0.95 for lateral margin, p=0.19 for vertical margin). Local recurrence was detected in 3.9% of the CSP group and 0% of the UEMR group.
Conclusion
The rates of negative margins for both lateral and vertical margins were comparable between CSP and UEMR. Despite this, two recurrence cases were observed in the CSP group. UEMR was as safe as CSP, with no intraoperative or postoperative adverse events reported. Furthermore, given that the preoperative diagnosis of adenoma may include a certain number of adenocarcinomas, UEMR may be considered the preferred method for endoscopic resection of NADAs ≤10 mm in size.
References
[1] K. Takizawa, Y. Takeuchi, M. Ohmori, J. Fujisaki, S. Yoshimizu, T. Iwai, T. Yamada, T. Suzuki, M. Takeuchi, M. Yoshida, A. Miyakawa, H. Furuhashi, M. Matsuda, H. Araki, K. Ohno, T. Shimura, T. Ohta, K. Mori, H. Ishikawa, T. Gotoda, D-COP study Group. COLD SNARE POLYPECTOMY FOR SUPERFICIAL NON-AMPULLARY DUODENAL EPITHELIAL TUMOR: A MULTICENTER PROSPECTIVE CONFIRMATORY TRIAL (D-COP TRIAL). ueg journal. 2021 Oct suppl. 27-28.
[2] Yamasaki Y, Uedo N, Akamatsu T, Kagawa T, Higashi R, Dohi O, Furukawa M, Takahashi Y, Inoue T, Tanaka S, Takenaka R, Iguchi M, Kawamura T, Tsuzuki T, Yamasaki T, Yamashina T, Nasu J, Mannami T, Yamauchi A, Matsueda K, Aizawa S, Mitsuhashi T, Okada H; D-UEMR Study Group. Nonrecurrence Rate of Underwater EMR for ≤20-mm Nonampullary Duodenal Adenomas: A Multicenter Prospective Study (D-UEMR Study). Clin Gastroenterol Hepatol. 2022 May;20(5):1010-1018.e3.
