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Detachable snare to prevent postpolypectomy bleeding

Open AccessPublished:July 25, 2020DOI:https://doi.org/10.1016/j.vgie.2020.06.008
      Pedunculated polyps with a thick stalk (>5 mm) have an increased risk of bleeding with resection.
      • Dobrowolski S.
      • Dobosz M.
      • Babicki A.
      • et al.
      Blood supply of colorectal polyps correlates with risk of bleeding after colonoscopic polypectomy.
      Bleeding risk can be reduced by placing a detachable snare around the stalk of the polyp before resection.
      • Brandimarte G.
      • Tursi A.
      Endoscopic snare excision of large pedunculated colorectal polyps: a new, safe, and effective technique.
      • Hachisu T.
      A new detachable snare for hemostasis in the removal of large polyps or other elevated lesions.
      • Iishi H.
      • Tatsuta M.
      • Narahara H.
      • et al.
      Endoscopic resection of large pedunculated colorectal polyps using a detachable snare.
      • Kouklakis G.
      • Mpoumponaris A.
      • Gatopoulou A.
      • et al.
      Endoscopic resection of large pedunculated colonic polyps and risk of postpolypectomy bleeding with adrenaline injection versus endoloop and hemoclip: a prospective, randomized study.
      In this video (Video 1, available online at www.VideoGIE.org), we demonstrate step-by-step use of a detachable snare for resection of a large pedunculated gastric polyp. The indications for use of a detachable snare include prevention or treatment of postpolypectomy bleeding, particularly of pedunculated polyps with a thick stalk or gastric polyps. The equipment used in this technique is the ENDOLOOP Ligature (Ethicon, Somerville, NJ, USA).
      The patient was a 39-year-old woman who presented with epigastric pain. Upper endoscopy found a large pedunculated polyp in the gastric antrum (Fig. 1). Resection of the largest polyp was planned. To reduce the bleeding risk, we planned to place a detachable snare around the stalk of the polyp (Video 1, available online at www.VideoGIE.org).
      Figure thumbnail gr1
      Figure 1A large pedunculated polyp with a thick stalk in the gastric antrum.
      First, we demonstrate how to bring the loop inside and outside the sheath. To advance the detachable snare, the yellow slide should be pulled toward the handle (Fig. 2). To withdraw the snare back into the sheath, the yellow slide should be pushed away from the handle (Fig. 3).
      Figure thumbnail gr2
      Figure 2Advance the detachable snare by pulling the yellow slide toward the handle.
      Figure thumbnail gr3
      Figure 3Withdraw the snare back into the sheath by pushing the yellow slide away from the handle.
      With the detachable snare withdrawn into the sheath, feed the sheath into the accessory channel. Advance the detachable snare by pulling the yellow slide toward the handle. Carefully maneuver the detachable snare over the polyp (Fig. 4). This can be challenging, given the size of the detachable snare in relation to the polyp. In this circumstance, the snare can be retracted into the sheath and gradually advanced to aid in maneuverability.
      Figure thumbnail gr4
      Figure 4Maneuver the detachable snare over the polyp. Ensure that the snare is around the entire polyp.
      Ensure the snare is around the entire polyp. If unsure, withdraw the snare into the sheath to mimic closing the snare. Carefully inspect the base to ensure the polyp is fully captured. Once this is confirmed, preparations to deploy the snare can be made. Tighten the detachable snare by closing the handle until resistance is met (Fig. 5). Check for blanching of the polyp.
      Figure thumbnail gr5
      Figure 5Tighten the detachable snare by closing the handle until resistance is met.
      Before deployment, the metallic release must be visible endoscopically, and the yellow slide must be flush with the base of the handle (Figs. 6 and 7). Deploy the detachable snare by fully opening the handle (Fig. 7). Remember that this should only occur once the yellow slide is flush with the base of the handle and the metallic release is visible endoscopically; if otherwise, the detachable snare may not release and could become trapped in the sheath.
      Figure thumbnail gr6
      Figure 6Before deployment, the metallic release (pictured here) must be visible endoscopically, and the yellow slide must be flush with the base of the handle. This will prevent inadvertent detachment of the snare within the sheath.
      Figure thumbnail gr7
      Figure 7Deploy the detachable snare by fully opening the handle. Note that the yellow slide is flush with the base of the handle.
      The polyp can then be safely resected on top of the detachable snare using standard polypectomy technique. The polypectomy snare should be above the detachable snare by approximately 1 cm (Figs. 8 and 9). If the polyp stalk is short, this may not be possible. In this case, the polypectomy snare should be placed midway between the polyp base and the detachable snare to obtain clear resection margins. In cases with high-risk bleeding, consider placing a second detachable snare.
      Figure thumbnail gr8
      Figure 8The polypectomy snare should be above the detachable snare by approximately 1 cm, or halfway between the base of the snare and the detachable snare.
      Figure thumbnail gr9
      Figure 9Postpolypectomy. The detachable snare remains intact.
      Common issues with using the detachable snare include (1) inadvertent deployment of the detachable snare within the sheath, (2) misdeployment, and (3) polypectomy below the detachable snare. To avoid inadvertent deployment of the snare within the sheath, ensure that the yellow slide is flush with the base of the handle and that the metallic release is endoscopically visible before deployment. In case of misdeployment, a loop cutter or endoscopic scissors can be used to cut the detachable snare. If polypectomy is mistakenly performed below the detachable snare, a clip or second detachable snare can be placed at the defect. Aiming the polypectomy snare approximately 1 cm above the detachable snare, or halfway between the base of the polyp and the detachable snare, can help in avoiding accidental polypectomy below the detachable snare.
      In summary, detachable snares are a safe and effective way to prevent polypectomy-associated bleeding with pedunculated polyps.

      Disclosure

      Dr Krishnan is a consultant for Olympus. All other authors disclosed no financial relationships.

      Acknowledgment

      Drs Chu and Soltani are supported by National Institutes of Health T32 training grant (5T32DK007191-45).

      Supplementary data

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