Today, cold snare clearing of FAP on the ASGE SuTab tip of the week. So I want to make the case that cold snaring has really taken over the management of FAP and these are colonoscopy tips and I'm going to talk primarily about colonoscopy but I think it's true in the duodenum also. The duodenum traditionally is a dangerous place to perform polypectomy. There's an increased risk of bleeding if you use electrocautery and there's an increased risk of perforation and there's an increased risk of perforation when you're trying to stop the bleeding. So the duodenum is just very challenging. I think cold snaring has just totally changed the approach to duodenal disease including in FAP disease that's away from the papilla. But when we're talking about the colon, there are some situations where we want to clear the polyp burden. One is the patient's had a subtotal colectomy rather than a total proctocolectomy. Their rectum is in place and we want to salvage the rectum and keep it under control. Second one is the ileoanal pouch patient and I will say that the cases I'm going to show you today are patients who disappeared from follow-up and this is one of the dangers after colectomy, especially after subtotal colectomy. If the patient disappears from follow-up, there's a risk of developing rectal cancer of course. But we also want to keep the ileoanal pouch clear and patients need to follow-up. There are some patients with intact colons who want to delay surgery and they have low polyp burdens and we sometimes will follow those with annual colonoscopy and clear those patients out too. And in my experience, that is actually quite feasible. It's not, of course, if there's a large polyp burden. In our approach to these, we count the polyps, so the nurse will sit in the back of the room and count the polyps. We count the total number of polyps and the number of polyps that are 10 millimeters or larger and we want to see those numbers decline over time with subsequent exams. Here's an FAP patient, a young man who had a subtotal colectomy and he's disappeared for seven years and he's coming back for follow-up. His family have encouraged him and he's finally coming back for follow-up. As we remove the polyps by cold sneering, we're going to count them and we've got up to 270 in this rectum and in one short procedure, we're going to be able to totally catch up with this young man's polyp burden. So we are removing polyps with a cold sneer that range from a couple of millimeters in size up to 15 millimeters in size. We're keeping two counts. There are two polyps removed at one time, so we go, for example, from 40 to 42 and we also keep a separate count for the polyps that are 10 millimeters or larger. The advantage of this is the safety, of course, and it's also quite effective. People used to use APC a lot when there are a lot of rectal polyps and I don't think it's nearly as effective if the polyps are sticking up at all. They're still going to be there when you get back, you have to treat them again, whereas cold sneer is quite effective at getting them out. And if we take all these out with a hot sneer, you know, the risk per polyp resection is quite low, but you multiply it times 270, there's a threefer right there, then you are really going to have some risk of having a delayed bleed and we want these people to come back. We want them to be comfortable. So this is a fabulous way to manage and reduce the polyp burden in somebody that you don't want to have additional surgery. So here's what it looks like at the end and a very effective way to control the polyp burden in this situation in FAP. This is an ileoanal pouch in an FAP patient who's had a total colectomy some years earlier and then disappeared from follow-up, which of course we'd prefer not happen so that we don't get into this situation, but it does happen from time to time. The pouch is predisposed to developing polyps. If you go up into the limb above the pouch, a lot of times the polyp burden will be very small compared to the pouch. So something about the stagnation of feces or something makes polyps grow in the pouch. But as long as there is not cancer in the pouch, we've got a strong incentive to save this because we don't want the patient to lose their pouch. They might end up with an ileostomy. They could lose a significant amount of bowel, plus they're going to need another operation. So much better for the patient to clear the pouch and cold sneering is just a fabulous way to do it. It's extremely low risk. Now this patient, I removed several hundred polyps, but over the course of three exams and we were doing these several months apart for about a year until we got to the point where we felt like the patient could go for a year. And again, we're counting the polyps each time. I don't think the counting has as much benefit if you're not reaching the point where you feel like you're cleared because you know the next time you've got to go back in and remove more polyps. This patient had a tendency to bleed quite a bit after the cold sneering. It usually would pass blood for a day or two, not enough to go to the emergency room, but some blood. And actually during the procedure, this is not a very bloody segment that I'm showing you, but he would typically get enough blood that I would feel like I would need to quit. And everybody's got their limit about how much they're willing to do in one day because of course we're not getting paid by the polyp. This kind of a patient makes you wish that you were getting paid by the polyp, but you know we have to do this sometimes because it's the best thing for the management of the patient. I set my all-time record for polyps removed in a single session in a pouch patient, not this one, at 342. This particular patient, I was removing about 100 to 150 polyps per procedure, and then usually it would get bloody enough, not too bloody right now in this case, but get bloody enough that I would sort of get discouraged and would have had enough for the day and would quit. So it took us about three sessions of 100 to 150 polyps to get to the point where we felt like this was clear. You can see everywhere you look in these patients, you'll see polyps, but you can just do this very safely. Now because of the bleeding, I'm actually using here a standard 10mm Captivator II because the braid is a bit thicker. It crushes the vessels better and you tend to have less immediate bleeding. So we're not using a specialty snare here as we did in the previous case, the rectal case, just to reduce the amount of bleeding. It does help with reducing it, but again we're going to count the polyps each time and once we get to the point where we're clear, then we'll extend the interval out to a year and hope that this patient will continue to be faithful about surveillance. He certainly was about the clearing process, but cold snaring, fabulous way to control the polyp burden in an FAP patient, a segment of bowel that you want to save. Cold snaring, great way to go in the rectum, in a pouch, in the duodenum. For more information, visit www.FEMA.gov

cold snare clearing

Familial Adenomatous Polyposis

colonoscopy

risk reduction

polyp burden management