Roberto Augusto Barros, MD and María José Monteverde, MD from the Department of Digestive Endoscopy, Ambulatory Gastroenterology Center (CEGA), in Campana, Buenos Aires, Argentina share this video case “Cold snare resection of a nonpolypoid lesion >45 mm.”
We show a a cold snare mucosectomy of a non granular laterally spreading tumor (LST) larger than 45 mm, located in the 83 years old patient’s ascendant colon. We used a piecemeal technique with wide margins resection to improve efficiency. There were no immediate or late adverse events. The 3-months endoscopic follow up with biopsy of the complete scar showed an efficient treatment taking into account the lesion size.
Although ESD, EMR with piecemeal, and right hemicolectomy were the treatment options, the team decided at diagnosis time to resect with cold snare because it was considered to be the safest for the patient. A specific snare designed for cold resections was used, and a ruled technique was implemented, which has been part of our daily practice for the last 5 years. This technique is described in the video. It implies a learning curve, since it is different from resections with electrocautery; it can be considered safe, as we have reported in our original manuscript “Safety and efficacy of cold snare resection of non-polypoid colorectal lesions (0-IIa and 0-IIb) of up to 20 mm” (Acta Gastroenterol Latinoam 2014; 44:27-32).
This may be the maximum expression of cold resection of a colonic non-polypoid lesion. However, this video has the sole intention of showing that the technique, when properly applied, could be part of the therapeutic options for non-polypoid colorectal lesions, even for larger ones.
ESD, EMR with or without piecemeal, and conventional polypectomy have complications related to electrocautery use, with efficiency rates still unsatisfactory for this type of lesions. However, the most frequently found non-polypoid lesions (between 6 and 10 mm size), are currently resected by means of electrocautery almost everywhere.
Considering cold snare for performing mucosae resections may motivate future research protocols, and also the development of new endotherapy material that could contribute to enhance the technique.
An endoscopist should aim to find a safe, efficient, replicable, rapid and inexpensive technique. We invite other groups interested in this issue to join us in this direction.
Perhaps, we could start challenging the current paradigm of electrocautery application in many of colonic non polypoid lesions.
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