Nonampullary Duodenal Adenomas: 9 Practical Tips for Safer Endoscopic Management: GIE | October 2026
What Are the Key Practice Points?
Find a duodenal adenoma? Check the colon. Sporadic duodenal adenomas are associated with a 2–7-fold increased risk of colonic adenomas. Ensure a high-quality colonoscopy has been performed within approximately 3 years. Routine small-bowel capsule screening is not required.
Characterise before cutting. Brunner gland hyperplasia, gastric heterotopia, follicular lymphoma and pyloric-gland adenoma can mimic a duodenal adenoma. Careful optical assessment, photography and usually superficial biopsy are appropriate.
Always identify the papillae before resection. Confirm that the lesion is not the major or minor papilla; inadvertent biopsy/resection can cause pancreatitis. A duodenoscope or cap-assisted examination may be necessary.
Large duodenal EMR is genuinely high risk. Post-polypectomy bleeding after hot-snare resection increases with lesion size and reaches approximately 25% for lesions ≥30 mm.
Routine clipping is not the solution. Complete closure is usually feasible only for relatively small defects. Aggressive clipping can itself injure the thin duodenal muscularis propria.
Cold snare is attractive for small, flat lesions. For most flat adenomas <15–20 mm, piecemeal cold-snare polypectomy offers very low bleeding risk. In larger lesions, however, lower bleeding comes at the cost of greater recurrence: 24.4% with P-CSP vs 2.3% with hot EMR + margin thermal ablation in one prospective comparison.
For large sessile adenomas, hot EMR + margin thermal ablation is preferred. MTA reduced recurrence from 17.6% to 2.3% compared with conventional EMR and should be incorporated after large-lesion EMR.
Recognise perforation immediately. Hot-snare resection carries approximately a 1% perforation risk. Inspect the defect after every resection; small injuries may be closed with through-the-scope clips, whereas larger defects may require an over-the-scope clip.
Sometimes the best resection is no resection. In frail, elderly or highly comorbid patients with large, relatively homogeneous low-grade lesions, the procedural risk may exceed the malignant potential. Surveillance can be a reasonable individualised strategy, although the evidence supporting this approach remains limited.
GastroAGI Takeaway
Duodenal adenoma resection should not simply copy colonic EMR practice—the duodenum is less forgiving. A practical strategy is cold snare for smaller flat lesions, hot EMR + margin thermal ablation for larger/sessile lesions, meticulous inspection for deep mural injury, and selective surveillance when procedural risk outweighs likely oncological benefit.
