Introduction

Endoscopic mucosal resection (EMR) has increasingly gained acceptance as a minimally invasive intervention for the treatment of duodenal lesions. Despite the overall good results, there can be significant morbidity associated with performing EMR in the duodenum. Data comparing hot- and cold-snare approaches in the duodenum are currently scarce.

Aims & Methods

Our aim was to assess the efficacy and safety of hot-snare EMR (H-EMR) versus cold-snare EMR (C-EMR) for the resection of non-ampullary duodenal lesions. A prospectively collected database of duodenal lesions treated using EMR at a single tertiary medical center between 2010 and 2023 was performed. Patient demographics, lesion and procedure characteristics, outcomes, and adverse events were analyzed using R statistical software. The lesion size and procedural time were analyzed using the Mann-Whitney U test while clinical outcomes were analyzed using the Fisher’s exact test. Cost savings were calculated from the averted use of clips.

Results

	Hot-snare EMR (n=46)	Cold-snare EMR (n=25)	P-value
Age, mean ± SD, y	66.72 ± 11.49	63.12 ± 11.61	0.12
Male gender, n (%)	20 (43.5)	17 (68.0)	0.08
ASA classification Class 1, n (%) Class 2, n (%) Class 3, n (%)	2 (4.4) 29 (63.0) 15 (32.6)	0 (0.0) 17 (68.0) 8 (32.0)	0.56
Antithrombotic use, n (%) Antiplatelet other than aspirin Anticoagulation Both	4 (9.1) 3 (6.8) 0 (0.0)	0 (0.0) 1 (4.3) 0 (0.0)	0.50
Size (mm)	25.93±15.53	21.68±38.40	0.003
Adenomatous lesions, n (%) Cancer in final histology	34 (73.9) 1 (2.2)	22 (88.0) 0 (0.0)	0.28 0.20
Procedural time, min	62.21±37.00	50.24±35.50	0.12
Technique En-bloc resection Submucosal lifting APC or CAST or STSC Adjunctive Hemoclips Hemostatic agent (e.g., Purastat or Hemospray)	31 (67.4) 44 (95.7) 16 (34.8) 25 (54.4) 3 (6.5)	20 (80.0) 23 (92.0) 5 (20.0) 4 (16.0) 3 (12.0)	0.29 0.61 0.28 0.002
Clinical outcomes, n (%) Technical success Immediate perforation Delayed perforation Delayed bleeding Stricture formation Recurrence	46 (100.0) 1 (2.2) 0 (0.0) 4 (9.1) 0 (0.0) 7 (22.6)	25 (100.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (15.4)	1.00 1.00 1.00 0.29 1.00 0.70

APC: Argon Plasma Coagulation
ASA: American Society of Anesthesiologists
CAST: Cold-forceps Avulsion with adjuvant Snare-Tip soft coagulation
STSC: Snare-Tip Soft Coagulation

Seventy-one cases of non-ampullary duodenal lesions resected using the EMR technique were included (46 H-EMR; 25 C-EMR). Fifty-one lesions were resected en-bloc (31 H-EMR vs 20 C-EMR) while 20 lesions were resected in a piecemeal fashion (15 H-EMR vs 5 C-EMR). Similar demographics, lesion, and procedure characteristics were observed in both cohorts. Technical success was 100%, and no delayed perforations occurred in either cohort. Lesions resected via H-EMR had higher rates of immediate perforation (2.2% vs 0%; p=1.0) and delayed bleeding (9.1% vs 0%; p=0.28) compared to C-EMR. Interestingly, recurrence rates were higher in the H-EMR arm (15.2% vs 8%; p=0.70). C-EMR technique achieved a crude cost saving from clips alone of USD $135 per patient compared to the H-EMR technique.

Conclusion

While both cohorts demonstrated excellent technical success, there was a trend towards lower adverse events and recurrence rates, as well as cost savings, when C-EMR technique was used for non-ampullary duodenal lesions. Larger prospective comparative trials are warranted to bolster the present evidence and shape the approach of tackling these rarely encountered but clinically significant lesions safely and effectively.

Introduction

A 52-year-old man was found to have a gastric submucosal protrusion lesion approximately 3.0 cm in size at the gastric antrum when he underwent gastroscopy. Endosonography and computerized tomography confirmed a gastrointestinal stromal tumor (GIST) originating from the muscularis propria with trans-mural growth.

Aims & Methods

Based on the growth pattern, endoscopic full-thickness resection(EFTR) was performed to enucleate the tumor. After submucosal injection, the mucosa near the lesion was dissected and used as a pedicle flap. Separated the lesion gradually and completely removed the tumor along the capsule to avoid intraperitoneal dissemination. Full-thickness resection leaved a large defect. Using purse-string suture to close the wound with a nylon rope and eight clips. And covered with a pedicle flap using four clips for reliable closure.

Results

The resection time was 44 minutes and the suture time was 16 minutes. The patient had no adverse events during the operation. Histopathology confirmed that it is a low risk g-GIST. The patient was discharged 5 days later without any significant discomfort. After 4 months, Gastroscopy showed complete healing.

Conclusion

Pedicle flap grafting can increase the safety of nylon rope suturing. Therefore, endoscopic pedicle flap grafting can be considered as an optional closure method for full-thickness defect after EFTR.