Hybrid resection versus conventional resection for laterally spreading lesions of the papilla

Abstract

Although conventional hot snare resection (CR) of laterally spreading lesions of the major papilla (LSL-Ps) is effective, it can be associated with delayed bleeding in upward of 25% of cases. Given the excellent safety profile of cold snare polypectomy in the colorectum, we investigated the efficacy and safety of a novel hybrid resection (HR) technique for LSL-P management, consisting of hot snare papillectomy plus cold snare resection of the laterally spreading component. A prospective cohort of patients underwent HR in a tertiary referral center over 60 months until December 2022. This cohort was compared with a historical cohort of patients who underwent CR at the same institution over 120 months until August 2017. The primary outcomes were recurrence and bleeding. Twenty patients underwent HR (14 female; mean age 65.2 ± 12.2 years). Median lesion size was 30mm (interquartile range, 25.0-47.5mm). Recurrent or residual adenoma (RRA) was greater with HR (58.8% [n= 10] vs 29.8% [n= 14]; P= .034). The odds ratio for recurrence was 3.6 times (95% CI, 1.2-11.0) higher with HR (P= .027). RRA was multifocal in 4 (40%) and had a composite RRA volume >10mm in 7 (70%). The median number of procedures required to treat RRA was higher with HR (4 vs 1, P= .002). There was no difference between CR and HR for intraprocedural bleeding (41.1% [n= 23] vs 25% [n= 5]; P= .587) or delayed bleeding (25.0% vs 10.0%, P= .211). There were no perforations. The novel HR technique for LSL-P management is associated with a high rate of RRA that is recalcitrant to treatment, without mitigating the risk of intraprocedural or delayed bleeding. Therefore, CR should remain the mainstay management option for treating patients with an LSL-P. (Clinical trial registration number: NCT02306603.).