COLD POLYPECTOMY

Tips and tricks

COLD POLYPECTOMY
Authors: Simona Badiu, Adelina Mușa, Daniela Elena Burtea, Cristian Țieranu, Adrian Săftoiu
Gastroenterology, Hepatology and Digestive Endoscopy Clinic of the ELIAS University Emergency Hospital, Carol Davila University of Medicine and Pharmacy Bucharest

Cold polypectomy is now the primary technique of choice for resection of polyps up to 10 mm in size (Fig. 1.1, 1.2) because it eliminates the risk of perforation and delayed bleeding, and visual feedback allows real-time assessment of immediate bleeding.

• The technique of using the cold loop is different from hot loop resection.
• The lesion should be positioned at 5 o’clock, the tip of the catheter a few mm away, and the loop should be fully open and placed completely over the lesion (Fig 1.3, 1.4).
• The loop must be closed in a continuous maneuver (“close and cut”) while maintaining the pressure on the loop or on the farm wall, respectively. When closed, the loop will also catch a normal tissue margin (Fig. 1.5).
• Insufflation should be maintained, as aspiration is not recommended as it may promote clamping of the submucosa, which may prevent cutting.
• If the lesion cannot be initially cut with a cold loop:

– hold the handle tightly closed for 10-15 seconds;
– maintain complete insufflation and avoid aspiration;
– make sure the endoscope is straight;
– angle the tip of the endoscope;
– straighten and stretch the catheter;
– partially reopen the handle (about 1/3 of the handle of the handle; avoid full opening);
– Slowly lift the lesion off the wall of the colon;
– be careful to release the trapped submucosa (a white band) under the lesion;
– close the loop completely again to cut the lesion;
– it is seldom necessary to apply electrocautery to a lesion which has failed to be cut.

• After cutting, wash with water jet at the level of the submucosal defect (hemostatic effect), with the relief of the colonic wall area underlying the resected area (Fig. 1.6, 1.7, 1.8).

IMAGE LEGEND

Fig 1.1, Fig 1.2 – Appearance in HD-WLE (high definition white light endoscopy), respectively in i-SCAN OE (optical enhancement) virtual chromoendoscopy of sessile polyp, <10 mm, PARIS 0-Is, well delimited, with cerebriform architecture , with adenomatous appearance according to ICE classification.
Fig 1.3, Fig 1.4, Fig 1.5 – Stages of cold loop polypectomy

• Fig 1.3 – Positioning the tip of the catheter a few mm away, with the handle open to the maximum and placed completely over the lesion.
• Fig 1.4, 1.5 – The loop closed in a continuous maneuver (“close and cut”) while maintaining the pressure on the loop, respectively on the colonic wall, with the resection of the polyp.

FIG. 1.6, FIG. 1.7, Fig 1.8 – Water instillation at the level of the submucosal defect (hemostatic effect), with the relief of the colonic wall area underlying the resected area.
Fig 1.7 – HD-WLE image, Fig 1.8- i-SCAN OE (optical enhancement) virtual chromoendoscopy image.