Choking with a snare to control immediate bleeding after cold snare polypectomy

A 75-year-old man underwent surveillance colonoscopy after endoscopic submucosal dissection for an intramucosal adenocarcinoma in his transverse colon. Colonoscopy revealed a metachronous colonic polyp in the transverse colon ([Fig. 1 a]). Macroscopically, this was a type 0-IIa lesion and, according to the JNET classification [1], it was type 2A, indicating a low grade adenoma ([Fig. 1 b]). Therefore, we performed cold snare polypectomy (CSP) using the Snare Master Plus (10 mm; SD-400U-10, Olympus, Tokyo, Japan). Bleeding continued for 60 seconds after CSP (immediate bleeding; [Fig. 1 c]), therefore we choked the mucosal defect, including the surrounding mucosa, with the same snare ([Fig. 1 d]). We continued the choking for 30 seconds, which stopped the bleeding ([Fig. 1 e]; [Video 1]). There were no complaints of hematochezia thereafter. Pathologically, the polyp was a low grade tubular adenoma, with no involvement of the lesion at the cut margin.

Fig. 1 Colonoscopic views showing: a a 9-mm polyp (macroscopic type IIa) in the transverse colon; b a JNET type 2A lesion on narrow-band imaging, indicating a low grade adenoma; c immediate bleeding from the mucosal defect after cold snare polypectomy, which continued for 60 seconds; d choking of the mucosal defect with the snare; e the appearance after hemostasis had been achieved by choking with the snare.

Video 1 Immediate bleeding after cold snare polypectomy is controlled by choking with the snare.

CSP is widely performed for subcentimeter polyps, where less delayed bleeding, coagulation syndrome, and perforation are expected [2] [3] [4] [5]. However, immediate bleeding sometimes occurs after CSP and hematochezia can cause anxiety [2] [3] [5]. In this case, choking with a snare enabled prompt and successful control of immediate bleeding, without the need to change to other devices, such as clips or hemostatic forceps.

Endoscopy_UCTN_Code_TTT_1AQ_2AD

Publication History

Article published online:
16 April 2021

• References

• 1 Sano Y, Tanaka S, Kudo SE. et al. Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team. Dig Endosc 2016; 28: 526-533
• 2 Takeuchi Y, Mabe K, Shimodate Y. et al. Continuous anticoagulation and cold snare polypectomy versus heparin bridging and hot snare polypectomy in patients on anticoagulants with subcentimeter polyps: a randomized controlled trial. Ann Intern Med 2019; 171: 229-237
• 3 Shichijo S, Takeuchi Y, Kitamura M. et al. Does cold snare polypectomy completely resect the mucosal layer? A prospective single-center observational trial. J Gastroenterol Hepatol 2020; 35: 241-248
• 4 Takeuchi Y, Yamashina T, Matsuura N. et al. Feasibility of cold snare polypectomy in Japan: A pilot study. World J Gastrointest Endosc 2015; 7: 1250-1256
• 5 Kawamura T, Takeuchi Y, Asai S. et al. A comparison of the resection rate for cold and hot snare polypectomy for 4–9 mm colorectal polyps: a multicentre randomised controlled trial (CRESCENT study). Gut 2018; 67: 1950-1957