Anchoring the snare tip using a small incision in the submucosa facilitates en bloc endoscopic mucosal resection for sporadic duodenal adenomas

Sporadic duodenal adenomas are rare with an estimated prevalence of 0.31 % – 4.6 % on upper gastrointestinal endoscopy [1].

Nowadays, endoscopic resection is the recommended treatment for sporadic duodenal adenomas thanks to its low morbidity and mortality when compared with surgical duodenopancreatectomy [2]. The reference technique of endoscopic resection is endoscopic mucosal resection (EMR) with snare [3] because of the high risk of perforation associated with endoscopic submucosal dissection (ESD) [4]. The rate of en bloc resection with free margins using EMR is lower than that with ESD, resulting in a higher risk of local recurrence. Nevertheless, it is commonly accepted practice to use EMR, despite its lower rate of curative resection, in order to reduce the perforation rate.

As previously demonstrated in the colon [5], snare-tip anchoring is effective at improving snare positioning and allows for an increase in the size of the resected area. This strategy could increase the rate of R0 resection compared with standard EMR.

We report here two cases where EMR was used to treat duodenal adenomas in the second part of the duodenum of two septuagenarian patients. After saline solution had been injected into the submucosa, we anchored the tip of a 25-mm snare on one side of the adenoma ([Fig. 1]; [Video 1]) using a small incision made with cutting current. The snare was then spread around the lesion and, being held stably, it was possible to resect the lesion en bloc. Finally, the lateral and deep resections were complete without adenomatous residual tissue.

Fig. 1 Endoscopic images of the procedure for duodenal endoscopic mucosal resection with snare-tip anchoring showing: a the injection of saline; b anchoring of the snare tip; c the snare being opened around the lesion; d the resected area.

Video 1 Duodenal endoscopic mucosal resection with snare-tip anchoring.

In conclusion, anchoring the snare does not involve any additional cost but seems to be an effective and simple way to improve the area caught during EMR, so allowing en bloc resection with free margins for duodenal adenomas.

Endoscopy_UCTN_Code_TTT_1AO_2AG

• References

• 1 Ghazi A, Ferstenberg H, Shinya H. Endoscopic gastroduodenal polypectomy. Ann Surg 1984; 200: 175-180
• 2 Klein A, Ahlenstiel G, Tate DJ. et al. Endoscopic resection of large duodenal and papillary lateral spreading lesions is clinically and economically advantageous compared with surgery. Endoscopy 2017; 49: 659-667
• 3 Lépilliez V, Chemaly M, Ponchon T. et al. Endoscopic resection of sporadic duodenal adenomas: an efficient technique with a substantial risk of delayed bleeding. Endoscopy 2008; 40: 806-810
• 4 Marques J, Baldaque-Silva F, Pereira P. et al. Endoscopic mucosal resection and endoscopic submucosal dissection in the treatment of sporadic nonampullary duodenal adenomatous polyps. World J Gastrointest Endosc 2015; 7: 720-727
• 5 Jacques J, Legros R, Charissoux A. et al. Anchoring the snare tip by means of a small incision facilitates en bloc endoscopic mucosal resection and increases the specimen size. Endoscopy 2017; 49: E39-E41