Upfront unroofing of subepithelial lesions using cold snare in the upper and lower gastrointestinal tract: a retrospective study from Switzerland

Background/Aims: Subepithelial lesions (SELs) are frequently encountered in the upper and lower gastrointestinal (GI) tracts during routine endoscopy. As a significant proportion of SELs harbor malignant potential, a definitive diagnosis with tissue sampling should be sought in most patients. However, small SELs (<20 mm) represent a clinical challenge because endoscopic ultrasound-guided tissue acquisition may not be as efficient under these circumstances. Furthermore, mucosal incision biopsies require equipment that is not universally available.Methods: We retrospectively investigated the diagnostic yield and safety of cold snare unroofing in an observational cohort.Results: A total of 71 SELs (41 in the upper GI tract and 30 in the lower GI tract) with a median size of 10 mm (range, 3–60 mm) were included. Unroofing resulted in a histologic diagnosis in 85% (n=60) of cases, with no further diagnostic procedures or surveillance required in 88.3% (n=53/60). The final diagnoses consisted of 10 different etiologies, including three GI stromal tumors, one neuroendocrine tumor, and 44 lipomas. No significant complications, such as bleeding or perforation, were observed.Conclusions: Cold snare unroofing represents an efficient and easy method for characterizing small SELs in the upper and lower GI tracts, offering a valuable alternative to mucosal incision-assisted biopsy (MIAB) and endoscopic ultrasound with fine-needle biopsy.