Everyone's gonna relax in this room when I'm done with this because I really appreciate that you guys asked me to speak on this because I, full disclosure, am the hugest fan of cold snare. And for all of these things that you just saw where you're like, I'm not gonna sleep well tonight, I took out that appendix seal orifice thing, the cautery effect is like crazy, this is definitely gonna perf, and I'm gonna be cold in the middle of the night, I have the solution for you, and it is cold EMR. Also, full disclosure, I am not an ESD person, I do have colleagues who do that, and I do think it takes a lot of training, and I think that it's good to have a couple people like Jason and others at your institution who will do those. So I have no other disclosures. So our objectives are gonna be talking a bit about why there's this movement, maybe away from hot snare, although everything you've seen this morning obviously doesn't really show that necessarily, pros and cons of hot versus cold snare polypectomy, what those risks are, which I think we kind of know, but sort of looking at hot versus cold, looking at the data supporting the techniques, and talk about some unanswered questions in cold polypectomy. So obviously, as we've been talking about, the goal is to remove the entire lesion. We wanna do this with the fewest adverse events that we can have, and then we ideally wanna minimize our cost, right? All these devices you've been seeing, APC, that costs money, caps cost money, clips cost money. So can we minimize our costs when we're taking out these polyps? Can we do it efficiently? Is it gonna take us, you saw those slides where it's like chance of taking it out under an hour. You know, that's a long time, right? That's why we all didn't go into surgery. So, and then how much training do you need? So we're gonna talk a little bit about these. So why are endoscopists going cold? So complications related to hot snare, as we know, include immediate and delayed bleeding and perforation, and those are the ones that we fear the most. So here's a lovely picture from Cyrus Paraka, who's sort of been a little bit of my distant mentor in cold snare polypectomy, because he is a huge fan, and showing how you can take out these big lesions with cold snare, and it can look beautiful in the end. So, you know, we know with 10 millimeter polyps, there's a lot of good data showing that you can remove these efficiently with both forceps and snare. I have to say that I am not a big forceps fan anymore. I was never really a video game player. I feel like you need to be like more coordinated to use forceps, whereas a snare, you know, I like the idea of putting a snare out, a small snare, and just, you can see normal around the polyp, and you just kind of have that comfort of knowing, you know, I got the whole thing out, whereas cold, you're kind of taking some, and it bleeds a little, and you take a little more, and I don't know, it just, to me, it's just sort of annoying. So I generally don't do cold forceps, by and large, for most things. So I do cold snare. And I'm also a little bit cost-conscious, you know, depending upon what I see as I'm going in to sort of what snares I'm using so that I don't pull out 20 different snares, so. So can we remove it all with cold snare polypectomy? So there is pretty good data looking at these polyps that are small, less than 10 millimeters, and that the complete resection rate, as you can see, is very, very high versus hot snare. And so based on this data, the Multi-Society Task Force and the ASG guidelines recommend cold snare for on-block resection of these small polyps. And you can see that there can be a little bit of immediate bleeding. I'm not even sure if you need to necessarily treat with clips. Sometimes, you know, just that water jet into the base where you're examining the base and also sort of able to tamponade often takes care of that. But really, severe delayed bleeding is so very rare. So what about larger polyps? So recent meta-analysis that was published in GIE in 2019 showed some excellent results with cold snare polyps of polyps greater than 10 millimeters with regards to post-polypectomy bleeding, completeness of resection, and residual polyp rates. So you can see here, residual rates were very, very low. We'll talk a little bit about, there's a little bit of a difference here, but with SSAs versus others, intraprocedural hemorrhage was very low, abdominal pain, and perforation obviously was zero. So that's sort of a big thing to remember, right? You're not gonna perforate patients using cold snare. And we were talking about margin and worried about taking normal margin. I worry not at all about taking normal margin. In fact, I take plenty of normal margin. So looking at polyps up to 15 millimeters, a recent randomized control trial that was published in GIE by some of the people who are doing a lot of the pioneering in cold snare. This was 235 patients randomized to cold snaring, cold EMR, hot snare, or hot EMR for non-pedunculated polyps that were six to 15 millimeters in size. And the overall incomplete resection rate was very, very low at 2.4. You know, remembering these are experts doing this, right? This is not my data or necessarily your data, but it certainly is a really low recurrence rate. Cold snare polypectomy took less time and no serious adverse events. And so, you know, as much as we use these small snares and you think, oh, this is just gonna take me forever, it is amazing how quick it can be, even with a cold snare. And you get faster as you do it. And, you know, you've sort of seen some examples of big, huge polyps that people are taking out. And I try to tell my fellows, you know, I didn't start with five centimeter polyps. I think you start small. You start with two centimeter polyps. You refine your technique. You figure out what you like. You figure out what snares you like. You figure out what injectate you like. You know, things like that. Little underwater tricks that you might use. So it's sort of a gradual process that's been for me over the last about five to 10 years. So looking at cold EMR for large serrated lesions, SSLs tend to have very little submucosal fibrosis. So they are often very easy to remove with cold snare. There was a recent large studies that have showed no serious adverse events. And residual polyp rates, though, tend to be somewhat higher in these lesions. And a little bit of this is probably related to sometimes not being able to really see the margin well. So I think it's really important that your technique is such that you're making sure you see the margins. You have a good submucosal injectate that has some contrast so you can really see where the margins are. I tend to not mark margins because I try to just do completely cold. I also like to use epinephrine. And Michael Bork has looked at this as putting a little bit of epinephrine. Not a lot, because there is some evidence that if you put the usual 1 cc in 10, patients can have pain, which the beauty of cold is that you know that they're not perforated. You know they don't have post-polypectomy syndrome. But they will have pain. It's sort of like a local ischemia. So I tend to just do very, very like 1 to 400,000, just enough so that there is not a lot of that bleeding that's not clinically significant, but it's going to muck up the field for you so you can't see the edge of your margins as well. So I always put a little bit of epinephrine every time I do resection. I don't know what the other people do in this room, but that's what I do. And again, sort of this careful examination of the base, like we were just looking at, putting water in the base and really looking carefully to make sure that you've got the lesion out. I'm pretty convinced that the recurrence rates that we see, especially when we're doing these big polyps, is not so much the edge necessarily. And I'll show you some videos, but it may be more at the base that we're having trouble. So when we talk about hot snare and adverse events, I mean, these are the things that we, again, lose a little bit of sleep on. Post-polypectomy bleeding rates anywhere from 2% to 7% in big series. And the need for clipping, it is suggested now that polyps that are larger, greater than 2 centimeters, have a higher risk of bleeding. And you can see here in this study, show delayed post-polypectomy bleeding with no clip closure was much higher than those who had clip closure. There was also, interestingly, although I'm not sure if it's just a small number, increased abdominal pain and perforation in the post-polypectomy syndrome in those who did not have clip closure. So we know that we can, we think that we can decrease the risk of delayed bleeding in patients if we do clip closure. But we also know that it's sometimes hard, these big lesions, how to clip these things closed. So you do a big defect, you want to clip it closed. And I actually asked Doug Rex about that, because he is a big, take out these huge things. And what he would do is sort of go in the base and close the base, kind of almost like two layers, close the base, and then close over that. And so that's a lot of clips, number one, which I realize is cheaper than admitting someone for a perforation and getting a right hemicolectomy. But also, does that affect surveillance of the site later? So do you clip in any adenoma that you didn't realize was there, and maybe it's beneath the surface? So something to think about. And there is this ongoing US Large Polyp Consortium study that I'm not sure when that data is going to be available, but that's ongoing. So more about hot snare polypectomy and prevention of post-polypectomy bleeding. And this was actually just published this month. I happened to pick up my GIE, and I was like, I'm going to really impress you guys that I got hot off the press. So this is a meta-analysis of randomized controlled trials to assess the efficacy of clipping to prevent adverse events after EMR of proximal non-pedunculated larger than 20 millimeter polyps. And after looking at all these studies, they really boiled it down to four randomized controlled trials, where they actually used almost the raw data from those studies. And they examined right-sided lesions where bleeding after hot snare we know is more common, and found that clipping was effective in preventing post-EMR bleeding, regardless of patient factors. So renal failure, anticoagulation status, and all those things. So this is something that we probably need to do if we're taking out big lesions on the right side to decrease that risk. But then the question would be, is cold snare polypectomy, could that be a game changer, where we don't have to do all of that, and we don't have to worry about bleeding, and we don't have to worry about clipping? Because clipping can really be challenging in some of these big lesions that we're taking out now. So when we're looking at cold snare, again, talk about a submucosal injection really loosening up the submucosa to help with snaring. And again, I always use epinephrine. It will help with the immediate bleeding, just the small little stuff, not the bigger bleeding. But again, I don't tend to see that kind of bleeding when I'm doing cold snare. You don't have any eschar that sloughs off, leading to bleeding. There's no ulceration. Studies conducted on patients who take antithrombotic therapy show that the risk of even a single or multiple agents did not really increase the risk after cold snare polypectomy. I do a lot of cold snare. The only patient I had who bled, who actually got admitted and got two units of blood, had started back on his blood thinner the next day. So I think it's always challenging. You're sort of like, you do this, and you're like, hmm, when should they restart? And I don't always have a great answer. I typically just sort of look at the reason why they're on it. If it's something that's sort of a-fib and they can wait a couple days, I usually have them wait. We always do things based on like our most recent complication, right? So typically I'd be like, oh, you can just start the next day, it's fine. And then after that happened, I maybe think about it a little bit more. So there are some reports of perforation with cold snare. I have never had one. There's always time for that first. But I think some of the reports were when they were yanking the snare into the sheath, sort of guillotining it on the scope. So I would not recommend that. I think if you can't close the snare, you got too much in there. So you just need to open a little bit and re-grab it. So that's what I'd recommend. Sometimes you just get those fibrotic pieces. I think the challenge with cold snare, I think, is those areas of fibrotic bands. And I think anytime, I mean, this is my experience and you can talk to everybody else here, but when you have a bulky lesion on a fold, I kind of imagine that it's just flip-flopping a lot. So when you go to resect it, there's always that linear band of fibrosis, which I sort of imagine is maybe that versus the flat ones that don't flip-flop, the ones that have any bulk to them flip-flop. So you get that band of fibrosis, which can be hard to tackle. So I think there's someone's talking about hot avulsion today, which is also my other favorite technique for those areas. So sometimes you do get stuck with cold snare with those fibrotic bands that can be challenging. Trying some underwater techniques also can help with those areas. This is just sort of a compilation. This is from Heiko Pohl that shows the here, all these studies above are hot snare and below is cold snare. You can see no bleeding, no perforation and no post-polypectomy syndrome. So this is why I'm saying you will sleep well at night if you try cold snare. So pedunculated polyps typically felt to have need to use heat for. There was recent data looking at small ones. I don't know if this is like overwhelming to you guys. If it's a thin stock and less than 10 millimeters, I don't know that it's like so amazing that you could take those out with cold snare. Cold snare appears to be safer than hot snare. I do find when I do pedunculated polyps, even small ones that I get some bleeding and sometimes I have to put a clip there. Delayed post-polypectomy bleeding was 4.7% for hot snare and zero for cold snare. But I thought was interesting is that 98% of the hot snare used clips, which I thought kind of the point of using the hot snare was at least for these small things. You know, I think if you have a big thick stock, you know there's gonna be a vessel there, you're gonna clip those. But for small ones, I guess I normally don't clip close hot snare for a pedunculated polyp. But in this series, 98% were clipped and 44% of the cold snares were clipped. So I don't know. So that's sort of food for thought. So the advantages of this study of cold snare include a shorter total procedure time, fewer clips used and lower delayed bleeding. So for things like this where you can put a little cold snare around there, those will work great. So going on to duodenal polyps, which are many people's least favorite things to do. Can we find similar results for hot snare versus cold snare? And Cyrus Baraka has some beautiful pictures of some serious wide field cold snare, small bowel polypectomy, which I've tried to emulate. And I don't know, you know, they bleed. They just bleed, like the immediate bleeding to me just makes it very hard to see margins and it's very frustrating no matter how much epi I use. This was a study published by Greg Ginsberg, 10 year data on hot snare EMR of sporadic non-ampullary adenomas, 142 patients. There was significant bleeding in 11%, eight with delayed bleeding. They clipped 37% and 23% of patients had recurrence, which is sort of the problem with these, right? And no perforation. So the question is with this bleeding, immediate and delayed bleeding, can we improve on this using cold snare? So there are a couple of recent retrospective studies published looking at cold snare of these non-ampullary adenomas. And this is actually a picture of Cyrus at one of his polypectomies. There was one study done out at UCSD of 110 patients with a polyp size that actually is not like too impressively large, 12 to 15 millimeters. And they showed similar intra-procedural bleeding with no delayed adverse events in cold snare versus hot. But of note in this study, APC was used in both groups. So it's kind of a little bit, you know, it is a little heat there. It's not totally cold. So, you know, I'm not sure exactly what to make of that. And then Cyrus Paraka at Henry Ford looked at 43 patients doing cold snare, and he does these really big adenoma resections. It's pretty impressive. 10 to 70 millimeters with a mean of 25 millimeters. Did find residual adenoma in almost half. Odds increasing with size of polyp, which we know is similar in the colon, right? The bigger they get, the harder it is to get no residual adenoma. He's found no perforation, no post-palpectomy syndrome or delayed bleeding. So forgive me any of the vendors out there who if I forgot to add their cold snare on, but, you know, back when I first started doing this a number of years ago, there were two. There was the Xacto and then the Captivator. Actually, the Xacto was the original and then the Captivator cold came on the scene. And now in the US, actually, I was looking up on the computer because I actually don't know all of these, but Microtech has two in two different sizes. So there's oval and there's diamond. Xacto is sort of the diamond shaped one. There's Captivator cold, which is a round one. They may have another one. Actually, I'm not sure. There's Diversitech has a lasso shaped one that's round and oval. Olympus has their Snare Master Plus. So there are lots of ones to choose from. And I think really, as you start doing this, you just need to see what you like. I like the Captivator cold for bigger, bulkier center. I might like the Xacto for the edges. And they're not that expensive and they do kind of get deformed over time when you're taking out big polyps. So I don't feel bad about using two snares. So you kind of got to test and see what you like. I mean, the Captivator cold is sort of stiffer. So I find like it's sort of easier to sort of push down and have the lesion pop up through the snare versus the Xacto. So I would just recommend, especially if you guys are at the hands-on sessions and there's different snares to try to see what you like. Some are rotatable if that makes you excited or not. I don't think that there's just like one good one out there that you definitely have to have, but just sort of try. And like I said, with my fellows, I tell them just start small, try the different things. I mean, that's how I learned, because this is not something that you're just going to learn in one session. So what Injectate I like, what Epi I like, but which Injectate, right? So there's sort of a lot of different things I think you just sort of have to learn. And I think as we learn what you like, and as we go on, there's going to be newer and newer devices and Injectates for you to try. So what polyps can we tackle with cold snare? So when you're looking at this polyp, you might be like, God, that is really big and bulky, and that is definitely going to have to be hot snared. But what is so interesting, as you inject contrast, you will see that it starts flattening out, right? The thing that was sort of doing this, you inject it and it sort of all sort of raises it up, and you realize that, you know, this is actually just sort of a convoluted polyp that you can take out with cold. And so what you do is just go around the edge, and I'll show some videos of really getting normal edge, which is the key. You gotta get normal edge. You can see clearly here, you know, and this is why I'm convinced that when we have residual, it's not from the edge, because you can go around and you can get clean edge, clearly, in a number of these polyps, and know that you're not leaving stuff there. It's sort of at the base, where you're seeing little ditzles here and there that I personally think, you know, as you're looking at this base, I mean, you guys can all look and see, like, what do you think? Like that, that doesn't seem good. I don't wanna leave that. I wanna leave that. I don't wanna leave that. But this edge, I mean, look how beautiful that is, right? There's just no way there's adenoma there, at least I think. So here's another nice video from Heiko, and this will show, you know, start with the hard part, and look at his snare. You see where it is? It's half normal, half polyp. So that's the key, is just to get some normal, and the beauty with cold snare is, it doesn't matter how big you make that, you're not gonna cause trouble, because there's not gonna be thermal effect. You're not leaving the world's hugest ulcer when you're done. So again, methodically going around, use a lot of water. The epi you can see here gives you nice hemostasis, because you don't have the cautery effect that's going to coagulate, and get good edge, and just go around, try and be really methodical about placing the snare, so you're not leaving islands, which can be, as we were talking about, challenging to deal with. It's much easier when you're sort of taking it as part of the polyp. And again, you wanna progress with overlapping pieces. Try to get that snare right to the edge of where you wanna resect. Try not to leave small islands. The other great thing with cold snare that you can do, is you can really get that bass, and I think that Jason was showing that in his last video, where he saw those pieces left that he wanted to take out. So you can snare the bass too. You don't have to worry about it. Sometimes it's hard, you have to loosen it a little, open the snare a little, let a little submucosa drop out, but you can go back and snare the bass. And I really think, personally, with the residual rates that we're seeing, that can be hot in the 20s, I think it really has to do with the bass. So again, can these bulky sessile polyps be removed cold? And I think you guys should try it, and see, and surprise yourselves that it can be removed cold. Again, with that injectate, sort of flattening everything out, and just start methodically doing it, and it doesn't take that long. Like you look at this huge polyp, and you're like, ugh, and you just start going, and 15 minutes later, it's gone. So, I don't know, I love the technique, as you can tell, so. I like to sleep at night. So, in summary, the cold revolution continues. I think we're gonna see more and more of this. I mean, companies are coming out with these devices all the time. I think for polyps that are less than 10 millimeters, cold snare is the standard of care. Again, really carefully delineating the margin. I mean, the other thing that I impress upon my fellows is you gotta have the scope, has to be straight, right? You have to be able to do with the scope what you wanna do. If it's looped, I mean, we get a lot of referrals for big polyps that aren't that big. I just imagine that since it was a little tough to get to the secum, that they had 160 centimeters of scope shoved in there, and then you can't do anything. So, the most important thing is technique, and getting there nice and straight, so that you can move the scope so you can get to the margins. I mean, you know there are those times that they're just not in a good spot, and you're just cursing yourself because it's right around the patek flexure, and you're sort of pushing up, and it's there. And you just don't feel as good about it when you're done, right? So, I think careful delineated margin. Think of using a cap. It's sort of have a love-hate relationship with the cap. It's like, do I want the blinders? Where's it gonna be exactly when I get in there? Or if I get in there and it was hard to get in there, do I wanna come out and put a cap back on? You know, these decisions that we have to make in the heat of the moment. But really, try to get in a really good position so you can see everything. Examine it, inject it. I think there's no harm. We don't wanna inject tattoo there, but if you inject, you put an injectate in some saline, and it doesn't lift well, or you don't think you can take it out. It's bigger than you thought. You inspected it, and now it looks too big. There's no harm in leaving it and sending it to someone else if you feel uncomfortable doing it. But again, with cold snare, I think you can really go to town on these, and have some great outcomes. We know it's fewer adverse events, and we'll wait to see this large polyp study, what those results are. But I think it's pretty promising. Thanks. Thank you.

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