Prophylactic saline-immersion snare-tip vessel coagulation after colorectal endoscopic resection

Endoscopic mucosal resection (EMR) for large colorectal adenomatous lesions is hampered by a relevant risk of post-EMR delayed bleeding [1] [2]. Patients who have proximal lesions and/or are on antithrombotic treatment are at higher risk for such delayed bleeding [3].

Post-EMR prophylactic vessel coagulation has been previously standardized as the application of a low-voltage current using hemostatic forceps [4]. However, this requires a time-consuming device exchange, as well as an additional cost. In addition, the application of a low-voltage current by a relatively large forceps may result in deep thermal injury.

A recent peroral endoscopic myotomy-based series reported that a high-voltage coagulation current delivered through a dedicated knife in a saline-immersion setting maximizes the coagulation effect, preventing unintentional cutting of the vessel wall [5].

We present the case of an 84-year-old woman who underwent an underwater piecemeal EMR (Captivator II, 15 mm; Boston Scientific, Marlborough, Massachusetts, USA) for a large (50 mm) right colon laterally spreading tumor granular-type without endoscopic features of submucosal invasive cancer. To prevent delayed bleeding, prophylactic saline-immersion coagulation was performed at the end of the procedure ([Video 1]).

Prophylactic saline-immersion coagulation for prevention of delayed bleeding after endoscopic mucosal resection for right colonic laterally spreading tumor.Video 1

The snare tip was gently placed in contact with the visible vessels and a high-voltage coagulation current (ForcedCOAG E4.0, ERBE VIO3; ERBE Elektromedizin GmbH, Tübingen, Germany) was delivered. This resulted in progressive presealing of the vessels without any cutting effect ([Fig. 1]). The patient was discharged 4 hours after the procedure with no relevant post-procedural symptoms. No delayed bleeding or other adverse events were reported up to 30 days after the procedure.

Fig. 1 Endoscopic images of saline-immersion coagulation. a Blood vessel identification (dashed line) after endoscopic mucosal resection. b Prophylactic snare-tip coagulation. c The vessels appear whitish after application of the high-current voltage under saline immersion. d Resection bed after saline-immersion snare-tip vessel coagulation.

This novel technique aims to reduce the risk of delayed bleeding after endoscopic resection using a one-device, cost-effective, and time-sparing approach. It also highlights the potential applications of saline-immersion coagulation in the field of endoscopy, which appear to be universal and irrespective of the technique, device, or type of current adopted.

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Citation Format

Endoscopy 2024; 56: E622–E623. doi: 10.1055/a-2353-6039

• References

• 1 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297
• 2 Albéniz E, Montori S, Rodríguez De Santiago E. et al. Preventing postendoscopic mucosal resection bleeding of large nonpedunculated colorectal lesions. Am J Gastroenterol 2022; 117: 1080-1088
• 3 Spadaccini M, Albéniz E, Pohl H. et al. Prophylactic clipping after colorectal endoscopic resection prevents bleeding of large, proximal polyps: meta-analysis of randomized trials. Gastroenterology 2020; 159: 148-158
• 4 Bahin FF, Naidoo M, Williams SJ. et al. Prophylactic endoscopic coagulation to prevent bleeding after wide-field endoscopic mucosal resection of large sessile colon polyps. Clin Gastroenterol Hepatology 2015; 13: 724-730
• 5 Capogreco A, Hassan C, De Blasio F. et al. Prophylactic underwater vessel coagulation for submucosal endoscopy. Gut 2024; 73: 1049-1051