Cryoballoon treatment of endoscopically unresectable duodenal adenomas

Snare polypectomy and endoscopic mucosal resection (EMR) are effective and widely utilized for treating duodenal adenomas. However, circumferential, recurrent and fibrotic adenomas can be challenging to treat with these techniques.

To develop a safe and effective treatment for these challenging lesions.

Between 2022 and 2024, a retrospective review was performed for all patients treated with cryoballoon for duodenal adenomas at two institutions. Cryoballoon focal ablation was performed using nitrous oxide, in which a 1-second "pre-puff" of nitrous oxide was performed, followed by delivery for 10 seconds to 14 seconds. Repetition was performed as needed. Surveillance endoscopy was performed at 3 months to 12 months post-ablation to assess efficacy.

A total of ten individuals were treated, including six patients with recurrent adenomas following previous incomplete endoscopic resections, one patient with an extensive flat adenoma surrounding an ampullary polyp that could not be resected with a snare, and two patients with circumferential sessile duodenal adenomas longer than 5 cm that were considered unresectable by EMR. Follow-up endoscopy demonstrated no efficacy (< 20% improvement) in the two patients with circumferential sessile adenomas. Of the eight patients with non-circumferential adenomas, three had no residual adenoma. Five had significant improvement with < 40% of the adenoma remaining and were treated again with cryoballoon (3) or cold snare (2). Three of the five patients had no recurrence following the second treatment. The remainder are awaiting repeat endoscopy. Seven patients were treated as outpatients and had no adverse events. Two patients undergoing concomitant snare ampullectomy were hospitalized for observation; one developed mild pancreatitis and was discharged following a 48-hour admission, and the second patient was asymptomatic.

Cryoballoon treatment may be effective for non-circumferential flat duodenal adenomas that are not amenable to snare polypectomy or EMR, such as those with severe fibrosis from prior treatment. More than one treatment may be required. However, the treatments are safe and well-tolerated. Limited experience in two patients suggests that cryotherapy is not an effective treatment for bulky circumferential adenomas.