Hello and welcome to another episode of Tech Talks brought to you by the ASGE. I'm Prateek Sharma from Kansas City and it is my pleasure to introduce today's topic which is cold snare polypectomy. Now this is a timely topic because cold snare polypectomy is being increasingly used during colonoscopy now both for small as well as for larger polyps. Today our expert is Dr. Cyrus Piraka who will be walking us through cold snare polypectomy during colonoscopy. Thank you Dr. Sharma for the kind introduction and thank you for the opportunity to participate in this Tech Talk on cold snare polypectomy and the use of the X-Acto snare. Cold snare polypectomy has really changed my practice in the past 8 to 10 years. This is largely due to the fact that it provides a high level of efficacy and a safety benefit above other techniques. The reason for its high level of efficacy has to do with the fact that with snare polypectomy you are able to remove the entire polyp on block with a cup of normal tissue which you may not reliably be able to do with the use of cold forceps. And from a safety perspective the benefit here has to do with the fact that it appears that the main adverse events associated with polypectomy are cautery based such as transmural burn causing post polypectomy syndrome, perforation which requires a high amount of electrosurgical energy to cut through the muscularis propria layer, and delayed post polypectomy bleeding which we believe to be related to the unroofing of coagulum that is covering a thermally injured arterial branch. And that doesn't appear to happen with cold snare polypectomy either. The technical approach to removing a polyp is very similar to that with hot snare polypectomy in that you want to optimize your scope position to get the polyp in the lower half of the screen if possible to optimize your view and ability to approach the polyp. And you want to get the snare really opened around the polyp of the cup of normal tissue. I think this is really the key is to put the snare where you want it to end up and sometimes using the tip of the snare to pivot into position is helpful. But often opening the snare above it deflecting down rather than pushing the snare is the key to removing these polyps. And you can do it rather quickly when you get comfortable with it. The X-Acto snare we'll look at in a little bit is the first commercially developed snare dedicated to cold snare resection and has a few advantages for that specific purpose and we'll look at that in a little bit. This is our opening like a YouTube video of an X-Acto snare from US Endoscopy. And what you see here is that it has a similar design as to conventional snares and hot snares with a handle similar to that of a hot snare. The main difference you may notice is that there's no cautery attachment to this snare because cautery is not an option on this one. You may notice about this snare is that it's rather small. It's about nine millimeters in diameter. It's thinner than a conventional snare by about a third and it's rather stiff compared to most snares. It doesn't have as much deflection or give. The sheath is also somewhat stiff as well. And it also has a unique shape partly related to the tip which you see in some snares that also is one of the things that allows you to deflect the snare into a better position around a polyp if you embed it into tissue. And the shape is not perfectly round or oval. It has kind of a unique shape. There's a back end to it as well that you may notice. And sometimes when I'm using the snare, I'll have the tech or the nurse kind of pull that back or sometimes I'll have them push it out depending on what I need for the polyp. What you'll notice is that similar to any snare, it works really essentially the same. The function is very similar to snares that we're used to, closure and opening similar to other snares. Sometimes there's a little extra extension here that comes out with opening that I'll ask the nurse to adjust to if need be. But often when you open it, it's in good position. Here we have our polyp. And what we're going to want to do is a few things. We're going to want to get our snare out and prepared and ready to go. So I'll often get the snare out of the scope, open up the snare and pull it back into the scope so that it's ready. We'll torque the scope to get the polyp in the lower half of the screen to make the approach easier. And then when we get the snare out, we can do a couple of things. We can use the snare tip itself to deflect folds of colon out of the way and to even push our way into good position. And often instead of just pushing a catheter up, some scope deflection will aid in positioning that snare around and along the plane of the base of the polyp and the colon so that when the snare closes, the tip goes towards the sheath rather than the other way around. We want it to be parallel to the base with some downward pressure below the polyps that it snags that tissue around the polyp. Here we're going to end up irrigating it to tamp it out any bleeding and we'll get a nice view of a clean resection here. Well, that concludes our session on cold snare polypectomy brought to you by the ASG Tech Talks. I hope you've enjoyed this section in which we have shown you some very practical ways of how to approach small as well as large polyps which can be removed by cold snare polypectomy. Until next time, thank you.

Tech Talks

cold snare polypectomy

colonoscopy

efficacy and safety

X-Acto snare