Considering the impact of the flexible polypectomy snare
29. Januar 2019 (online)
This year Endoscopy celebrates its 50th birthday by highlighting some of the landmark papers in the history of the journal. In this regard, the 1971 report by Professor P. Deyhle et al. from Erlangen University is certainly an example of a transformative contribution . The authors reported the development of a flexible wire loop diathermic resection snare, which we now refer to in everyday practice as the polypectomy snare. The original oval wire loop snare depicted in the Deyhle paper and shown resecting pedunculated and sessile lesions in [Fig. 1] is immediately recognizable to modern colonoscopists. Though variations in loop shape ([Fig. 1]) and wire construction have developed over time, the persistence of this device in much the same form as it appeared five decades ago is truly remarkable. Using the diathermic snare, Deyhle et al. resected six polyps up to 1.5 cm in size from the colon above the rectum. Whereas polyp resection was previously performed in the rectum using rigid proctoscopes and resection tools, polyp resection in the colon through colonoscopes and using flexible snares was a new paradigm. The trepidation and uncertainty they must have experienced in performing an operation previously possible only by open surgical resection, is suggested by their comment: “Until we have more experience, we consider a period of hospitalization of 5 days after the operation to be necessary.” Contemporaneously, Hiromi Shinya in the USA, in collaboration with Hiroshi Ichikawa and William Wolff, also developed a diathermic snare and applied it above the rectum .
Could these inventors of the flexible diathermic snare have imagined the revolution in healthcare and in gastroenterology that their devices initiated? The impact of the flexible polypectomy snare on gastrointestinal care was almost immediate and profound. The malignant potential of colorectal polyps was well recognized prior to 1971 , and the only therapeutic option available to those with large colon polyps was open surgical resection. To accomplish the goal of polyp resection without surgery was transformative. The savings in mortality, morbidity, and costs achieved by converting colon polyp resection from a surgical to a colonoscopic procedure over the past 50 years is mind-boggling to consider. The potential of fiberoptic colonoscopy to alter health outcomes was largely realized by the invention and application of the flexible diathermic snare. Furthermore, this ability to remove polyps enabled and distinguished colonoscopy as a primary screening method, and as the natural follow-on test to all other positive screening and imaging tests. In addition to the dramatic improvement in outcomes initiated by colonoscopic polypectomy, flexible endoscopes and tools such as the diathermic snare dramatically transformed the specialty of gastroenterology. For many gastroenterologists around the world today, both their original opportunity to become a gastroenterologist and their current daily work schedules are the result of the great demand for colonoscopy and polypectomy.
Today colonoscopy is among the most widely and commonly performed medical procedures in the world. Certainly the public health impact of colonoscopy and polypectomy are greater today than any other endoscopic procedure. Through the 1980 s, clinical investigation in gastroenterology was dominated by upper gastrointestinal tract disease, including peptic ulcer disease and the discovery of Helicobacter pylori. Beginning with the great Sid Winawer and the National Polyp Study in the USA , sound scientific evidence started to appear demonstrating the value of colonoscopic polypectomy in colorectal cancer prevention. Long overdue, in recent years we have seen the technique of polypectomy subjected to scientific analysis. Although many investigators have advanced our understanding of effective and safe polypectomy techniques, the current trend of controlled investigation in technique is perhaps best exemplified in the systematic investigation of endoscopic mucosal resection by Michael Bourke’s consortium of Australian investigators . There have also been advances in routine polyp resection, such as the slow progression to cold techniques that began over two decades ago . All of this work has rested fundamentally on the still persistent polypectomy snare. Endoscopic submucosal dissection (ESD), developed by Japanese endoscopists for the treatment of early gastric cancer, has been extended to the colon , and is the first colonic endoscopic resection technique to move fundamentally away from the snare. The best niche for ESD in the colon remains a common subject of debate, and in Western countries ESD is a tool utilized by only a minority of colonoscopists, who are generally considered to be highly skilled interventionists. Developing tools for ESD that could give the technique the same practical value and widespread use that the simple flexible polypectomy snare has and continues to enjoy, is a major goal of endoscopic device companies and ESD practitioners.
For us as authors, the invitation to write this editorial has been a reminder that our careers as endoscopists, and investigators in colonoscopy technique and colorectal cancer prevention, have been enabled by the flexible polypectomy snare. We thank Professor Deyhle and his colleagues for their ingenuity in invention, and courage in application to patients, and to Endoscopy for the wisdom to publish a landmark work.
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