Incision and snaring: a simple trick to grasp flat colonic lesions

Endoscopic mucosal resection (EMR) is, nowadays, a well-standardized therapeutic technique for the treatment of gastrointestinal (GI) neoplasm limited to the mucosal layer. EMR is indicated for the removal of sessile or flat polyps smaller than 2 cm or for piecemeal removal of larger lesions [1]. Compared with EMR, endoscopic submucosal dissection (ESD) results in a higher en bloc resection rate and lower local recurrence rate, yet ESD has high procedure-related complication rates and is more time-consuming [2]. Especially in presence of flat lesions, grasping the lesions can be challenging. A hybrid technique solved this problem, although it is also a time-consuming procedure [3]. When sessile or flat lesions can be removed by EMR, one simple trick for grasping the lesion is, after submucosal injection, to create an incision in the normal mucosa in the fold beyond the proximal edge of the lesion where the tip of the snare will be inserted. Afterwards the scope is withdrawn slowly until the snare is completely open. Then the lesion can be grasped, deflating the bowel, and cut ([Video 1]).

Video 1 Incision and snaring technique for grasping and removing a colonic flat polyp.

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• References

• 1 Masci E, Viale E, Notaristefano C. et al. Endoscopic mucosal resection in high- and low-volume centers: a prospective multicentric study. Surg Endosc 2013; 27: 3799-3805
• 2 De Ceglie A, Hassan C, Mangiavillano B. et al. Endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions: A systematic review. Crit Rev Oncol Hematol 2016; 104: 138-155
• 3 Okamoto K, Muguruma N, Kagemoto K. et al. Efficacy of hybrid endoscopic submucosal dissection (ESD) as a rescue treatment in difficult colorectal ESD cases. Dig Endosc 2017; 29 (Suppl. 02) 45-52