Hot versus cold snare endoscopic mucosal resection for nonampullary duodenal lesions: consolidating the cold revolution into clinical practice

Background and Aims

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 snare and cold snare approaches in the duodenum are currently scarce. 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 nonampullary duodenal lesions.

Methods

A retrospective analysis of 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. The primary outcomes studied included complete resection, as assessed by the endoscopist through visual confirmation of complete polyp resection, as well as recurrence and adverse events, including perforation and bleeding. Cost savings were assessed thereafter.

Results

Seventy-one cases of nonampullary 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), whereas 20 lesions were resected in a piecemeal fashion (15 H-EMR vs 5 C-EMR). Similar demographics and lesion and procedure characteristics were observed in both cohorts. Complete resection was 100%, and no delayed perforations occurred in either cohort. Lesions resected via H-EMR had greater rates of immediate perforation (2.2% vs 0%; P = 1.0) and delayed bleeding (9.1% vs 0%; P = .28) compared with C-EMR. Interestingly, recurrence rates were greater in the H-EMR arm (15.2% vs 8%; P = .70). C-EMR technique achieved a crude cost savings from clips alone of $135 U.S. dollars per patient compared with the H-EMR technique.

Conclusions

Although both cohorts demonstrated excellent complete resection, there was a trend toward lower adverse events and recurrence rates, as well as cost savings, when C-EMR technique was used for nonampullary duodenal lesions.