HYBRID-BIOPSY ENDOSCOPIC MUCOSAL RESECTION: AN EFFECTIVE AND SIMPLE TECHNIQUE FOR FLAT COLORECTAL LESIONS

Hybrid resection techniques (Hybrid EMR-Hybrid ESD) have been described to facilitate complete removal of flat lesions. They may be useful in cases when the snare slips, which may happen in Laterally-Spreading lesions of the non-granular type (LST-NG), fibrosis due to previous resection attempts, and fatty tissue in the submucosa among other factors. However, endoscopists not experienced in ESD may not feel confident doing a circumferential incision with a dedicated knife or the tip of a snare, and it would not be safe if they are not adequately trained in this technique.

Here we report a new hybrid EMR technique especially useful when the snare slips when closed by the operator. After submucosal injection, a circumferential incision is made using a biopsy forceps, with subsequent bites around the target lesion. This incision allows to fit the snare avoiding slippage when it is squeezed. The lesion is finally cut with cold or hot technique. We have applied this technique in three colonic cases: 1) 7-mm flat lesion, slippage of snare was likely related to abundant fatty tissue in the submucosa; 2) 15-mm LST-NG flat lesion. 3) 15-mm residual lesion (IIa Paris Classification), slippage was related to fibrosis secondary to an incomplete previous ESD. In this case, a semi-circumferential incision was made with the tip of a K-snare (Pentax), and then it was completed with a biopsy forceps; finally, a 'piecemeal' resection with cold snare was successfully done (Video 1). Histology in all cases showed tubular adenomas with low grade dysplasia.

Hybrid-biopsy EMR is a simple method, to complete removal of flat lesions, devices needed are widely available, the cost is low, and it could be done safely by endoscopists not experienced in ESD. Improved design of biopsy forceps with rotability could make this technique even easier to apply.