The pivot maneuver is a snaring technique that we use when polyp tissue is oriented in a longer direction transversely than it is longitudinally, and we want to increase the amount of tissue that we snare at one time or potentially get a lesion that's up to a couple centimeters in maximum direction transversely on block. If we keep the snare oriented longitudinally, we'll tend to piecemeal more. So to perform the pivot maneuver, we usually want to pivot from right to left with a colonoscope that's easier than going left to right. We're going to pick a point that is usually located a few millimeters distal to the distal most part of the polyp. We'll put the snare tip on that point, then keep forward pressure on the snare sheath, and that allows the tip to stay there while we turn the snare over the polyp. So we end up like this. This is our pivot point. Keeping the snare tip anchored on that point has allowed us to turn the snare transversely over the polyp tissue. Here's the pivot maneuver on an SSL. Notice that the tip is being placed all the way to the right of the lesion, not really completely distal, but a little bit toward the distal side, and then we're shifting the snare to run transversely over this lesion, and we're going to remove it on block by hot EMR. Now, I've mentioned previously that I now currently perform cold EMR on almost all SSLs and prefer that because of the low risk of complications. This particular patient was participating in a randomized trial in which they were randomized to hot EMR, and so it's really an opportunity just to demonstrate the technique. And looking at the defect, you'll see that we got a nice on-block resection. It would have been more difficult to do that if we'd oriented the snare in the longitudinal direction, but the pivot maneuver allows us to go across this lesion that's oriented transversely. As many colorectal lesions are, they're longer in the transverse direction. Here's a granular LST, an adenoma in the proximally ascending colon. That's the valve just to the left, no evidence of cancer. Because this lesion is longer transversely than it is longitudinally, it's a good candidate for pivoting. So notice that we've selected a point to anchor the snare tip, which is to the right of the lesion and slightly distal. And we are going to push the snare into the wall at that point, and it's that anchoring of the tip that lets us turn the snare in the same direction as the long axis of the polyp. If we don't go a little bit toward the distal side, especially if we're on the proximal side of the cushion, the snare is going to tend to slip toward the cecum as we try to turn the snare. So we've got to pick the right point, a little bit distal and to the right. And we're doing this again now. We have the tip in the submucosa and we're turning the snare. It's a 15 millimeter snare. We're not taking huge amounts. We're not getting too greedy, but we are being a little bit more efficient by orienting the length of the snare in the same direction as the long axis of the polyp. And that's the pivot maneuver. This is the kind of lesion that's longer in the transverse direction that the pivot maneuver is often helpful for. We're going to take the last couple of pieces here with the snare oriented in the longitudinal direction. But the pivot maneuver helped us get started here, helped us get oriented in the long axis of the polyp. Here's another granular LST in the proximal ascending colon. This lesion is actually longer in the longitudinal axis of the colon, but the last piece is longer in the transverse axis. So to remove it, we'll use the pivot maneuver. We've selected an anchor point off to the right, turned the snare in order to capture this last piece. So this is the pivot maneuver. It's something that can improve the efficiency of snaring during EMR. Thanks and see you next week on the ASGE SuTab tip of the week.

pivot maneuver

polypectomy procedures

transverse direction

longitudinal direction

tissue snared