Post written by Muhammad Nadeem Yousaf, MD, from the Department of Medicine, Division of Gastroenterology and Hepatology, University of Missouri–Columbia, Columbia, Missouri, USA, and Ahmed Saeed, MD, from the the Department of Medicine, Division of Gastroenterology and Hepatology, University of Missouri–Columbia, and HCA Midwest Health, Kansas City, Kansas, USA.

EMR of nonlifting or fibrotic polyps may pose challenges, especially when the snare fails to capture flat or depressed fibrotic areas. We present a case series of the “cap-assisted snare capture” technique using the distal attachment clear cap as an adjunct to EMR for resection of residual fibrotic tissue.

In this video, we demonstrate a simple-yet-innovative cap-assisted snare capture technique to assist with resecting fibrotic adenomatous tissue that cannot be captured with conventional snare closure. This technique requires a distal attachment cap and a snare typically used during standard EMR. 

The steps involved are straightforward:

1. Apply a distal attachment cap to the tip of the colonoscope.
2. Use a soft braided hot snare, preferably 10 to 15 mm, around the fibrotic tissue.
3. Maneuver the colonoscope, so the cap is positioned over the snare.
4. Apply suction to pull the fibrotic tissue into the cap while simultaneously closing the snare around it.
5. Confirm the snare capture before proceeding with the resection.

Cap-assisted snare capture is a safe and effective technique for resection of residual fibrotic tissue after EMR. In our experience, the risks of perforation with this technique are low because using the small 10- to 15-mm flexible snare under the cap minimizes the risk of capturing deeper, unintended tissue. The distal attachment clear cap extends only a few millimeters, limiting the depth of the snare capture. 

The cap-assisted snare capture technique has proven to be a basic-yet-effective addition to the endoscopist’s toolbox for managing complex polyp resections in our experience. Given its simplicity and the availability of the necessary equipment in most endoscopy units, this technique can easily be adopted in practice. 

Illustration of the cap-assisted snare capture technique. Endoscopic evaluation of residual adenomatous tissue in the middle of a resected polyp after EMR (panel 1); a soft snare placement around the residual tissue (panel 2); endoscope maneuvering to position the cap on top of the open snare (panel 3); suction application with simultaneous snare closure to capture targeted tissue before resection (panel 4); and inspection of resection site for residual tissue, bleeding, and perforation (panel 5).

Read the full article online.

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