Detachable Snare Research Articles

Removal of jammed loop cutter and residual snare wire, after polypectomy with a detachable snare

Removal of jammed loop cutter and residual snare wire, after polypectomy with a detachable snare

Clinical outcomes of endoscopic detachable snare ligation for colonic diverticular hemorrhage: Multicenter cohort study.

The hemostatic mechanism of endoscopic detachable snare ligation (EDSL) for colonic diverticular hemorrhage (CDH) is similar to that of endoscopic band ligation, which is effective and safe. However, because reports on EDSL are scarce, we conducted a two-center cohort study to evaluate its effectiveness. This study analyzed 283 patients with CDH treated with EDSL at two Japanese hospitals between July 2015 and November 2021. Patient characteristics and clinical outcomes were retrospectively evaluated. A Kaplan-Meier analysis was performed to evaluate the cumulative probability of rebleeding after EDSL. A Cox proportional hazards regression analysis was performed to compare the effects of complete and incomplete ligation on rebleeding. The initial hemostasis success and early rebleeding rates were 97.9% and 11.0%, respectively. The time to hemostasis after identification of the bleeding site and total procedure time were 9 min and 44 min, respectively. Red blood cell transfusion was required for 32.9% of patients. The median hospital length of stay after EDSL was 5 days. The complete ligation rate of the early rebleeding group was significantly lower than that of the group without early rebleeding (P < 0.01). The 1-year cumulative rebleeding rate with EDSL was 28.2%. Complete ligation was associated with decreased cumulative rebleeding after EDSL (P < 0.01). One patient experienced colonic diverticulitis; however, colonic perforation was not observed. Complete ligation is associated with reduced short-term and long-term rebleeding. EDSL could be valuable for CDH because of its low rebleeding rate and the absence of serious adverse events.

Endoscopic submucosal dissection using a detachable snare for a large colorectal tumor with muscle retraction.

Endoscopic submucosal dissection using a detachable snare for a large colorectal tumor with muscle retraction.

Advancements in endoscopic management of small-bowel polyps in Peutz-Jeghers syndrome and familial adenomatous polyposis.

Before the development of double-balloon enteroscopy (DBE), the standard management of small-bowel polyposis was surgical resection. This is an invasive procedure that could lead to short bowel syndrome. In the 21st century, several new enteroscopy techniques were distributed worldwide, including DBE, single-balloon enteroscopy, spiral enteroscopy, and motorized spiral enteroscopy. These devices enable the diagnoses and endoscopic interventions in the entire small bowel, even in patients with a history of laparotomy. In patients with Peutz-Jeghers syndrome (PJS), endoscopic ischemic polypectomy with clips or a detachable snare is the preferred method for managing pedunculated polyps because it is less likely to cause adverse events than conventional polypectomy. Although polyps in patients with PJS always recur, repeat endoscopic resection can reduce the total number and mean size of polyps in the long-term clinical course. Endoscopic reduction of small-bowel intussusception caused by PJS polyps can be successfully performed using DBE without surgery. A transparent hood is useful for securing a visual field during the treatment of small-bowel polyps, and minimal water exchange method is recommended to facilitate deep insertion. Familial adenomatous polyposis (FAP) is a genetic disorder that increases the risk of developing colorectal cancer. Because jejunal and ileal polyps in patients with FAP have the potential to develop into cancer via the adenoma-carcinoma sequence, periodical surveillance, and endoscopic resection are needed for them, not only polyps in the duodenum. In cases of multiple small-bowel polyps in patients with FAP, cold snare polypectomy without retrieval is an acceptable treatment option for polyps that are 10 mm or smaller in size. Additional good pieces of evidence are necessary to confirm these findings because this narrative review mostly includes retrospective observational studies from single center, case reports, and expert reviews.

Clip with line-pulley securing technique with plastic detachable snare for endoscopic submucosal dissection defect closure

Video 1Clip with line-pulley securing technique with plastic detachable snare for endoscopic submucosal dissection defect closure.

Perforation-free removal of gastric gastrointestinal stromal tumors: Endoscopic inversion and strangulation of muscle layer and resection (EISMR).

Endoscopic resection for GIST has become more widespread in recent years because it is less invasive than surgery. However, when endoscopic resection is performed, a full-layer resection of the gastric wall is often necessary, and extensive suturing is required if perforation occurs, which is a technically challenging procedure. Recently, we reported a new method called endoscopic inversion and strangulation of the muscle layer and resection (EISMR), which consists of endoscopically inverting the muscle layer into the gastric lumen and strangulating the muscle layer with a detachable snare, followed by resection. The study comprised five consecutive patients with gastric GIST ≤50 mm in diameter who underwent EISMR procedures. The main outcomes of the study were en bloc resection rate, R0 resection rate, procedure time, and complications. The results showed that all five patients successfully underwent complete resection without perforation, and the en bloc resection and R0 resection rates were 100%. The median procedure time was 93 min (range, 58-120 min), and there were no major complications. We concluded that EISMR would be a safe and effective technique for endoscopic resection of gastric GISTs and may be an alternative to surgery or endoscopic submucosal dissection.

Endoscopic resection of a gastric gastrointestinal stromal tumor without perforation using a detachable snare.

Resection of gastrointestinal stromal tumors (GISTs) by endoscopic submucosal dissection (ESD) has recently been reported [1] [2]. However, when endoscopic resection is performed, a full-layer resection of the gastric wall is often necessary, and extensive suturing is required if perforation occurs. We report the case of a patient with a GIST that was completely resected safely and easily without perforation using the ESD technique in combination with a detachable snare.

Underwater endoscopic mucosal resection using a detachable snare for a pedunculated lesion located in the greater curvature of the upper gastric body.

Underwater endoscopic mucosal resection using a detachable snare for a pedunculated lesion located in the greater curvature of the upper gastric body.

S652 Prophylactic Epinephrine Injections for the Prevention of Postpolypectomy Bleeding: A Meta-Analysis

Introduction: Bleeding is the most common major complication from colonoscopic polypectomy. We performed a meta-analysis to evaluate whether submucosal epinephrine injections prevent postpolypectomy bleeding. Methods: The dataset was defined by searching PubMed for randomized controlled and retrospective studies published before December 2021 that compared the use of epinephrine (alone or with another preventative measure) to no prophylaxis for bleeding. Groups were defined as either epinephrine injection only (group A), mechanical prophylaxis via detachable snare and/or clip only (group B), combined therapy group (group C), and a control group. Group differences were analyzed by using a random-effects models. Effect sizes were calculated as Cohen’s d for continuous data or a log of the odds ratio (OR) for percentage (binary) data. Results: In all, we identified ten studies: six used in a prior meta-analysis and four additional studies (Table). Overall, 2,125 patients with 2,287 total polyps were included in nine randomized controlled trials and one retrospective chart review. Overall bleeding was lower in group A than in controls on the basis of five studies (OR, -1.038; confidence interval [CI] -1.560 to -0.515; p≤0.001). One study indicated that overall bleeding was lower in group B than in the controls (OR, -1.524; CI, -2.799 to -0.249; p=0.019) (Figure A). Early bleeding was lower in group A than in the controls on the basis of five studies (OR, -1.626; CI, -2.535 to -0.718; p≤0.001) and lower in group B on the basis of one study (OR, -2.719; CI, -4.175 to -1.263; p≤0.001) (Figure B). There were no significant group differences associated with late onset bleeding. Group A was significantly older than group C (Figure C) and had larger polyps than group B (Figure D). Homogeneity tests indicated homogeneity among the effect sizes suggesting examination of moderating variables was not necessary and there were no differences among the groups in terms of patient sex, polyp histology, polyp morphology, or stalk size. Conclusion: The results indicate that epinephrine prophylaxis reduces overall and early postpolypectomy bleeding but does not affect late bleeding.Figure 1.: Comparison of (A) overall and (B) early postpolypectomy bleeding in the epinephrine and control group. (C) Group A was significantly older than Group C. (D) Group A identified larger polyp size than Group B. Table 1. - Study Characteristics (NA, not available; mm, millimeters) Study Population Group Comparisons Number of patients Age (year) Number of polyps Polyp size (mean) (mm) Rohde NA A: Epinephrine B: No prophylaxis NA A: 70 (53–88), B: 65 (33–78) 40 A: 15 (7–28), B: 15 (11–35) Lee SH. Multicenter A: Epinephrine B: No prophylaxis 486 A: 51.6 ± 11.4, B: 56.8 ± 11.3 561 A: 14.5 ± 5.7, B: 15.0 ± 6.8 Hsieh Yh. Single center A: Epinephrine B: No prophylaxis 129 A: 62.9 (59.8–62.1), B: 64.9 (62.1–67.8) 151 A: 8.0 (8–13), B: 8.0 (8–11) Dobrowolski S. Single center A: Epinephrine B: No prophylaxis 69 A: 63.7 ± 9.7, B: 66.8 ± 11.5 100 A: 16.3 ± 5.4, B: 16.1 ± 5.9 Paspatis GA. Multicenter A: Combined therapy (detachable snare with epinephrine) B: Epinephrine 159 A: 61.7 ± 13.8, B: 64.5 ± 11 159 A: 27.1 ± 8.9, B: 26.3 ± 8.1 Kouklakis G. Single center A: Mechanical therapy (Endoloop with postpolypectomy clipping) B: Epinephrine 64 A: 57.9 ± 9.7, B: 58.8 ± 11.2 64 A: 25.6 ± 12.0, B: 27.0 ± 11.0 Di Giorgio P. Single center A: Mechanical therapy (detachable snare) B: Epinephrine C: No prophylaxis 488 A: 64 ± 9.2, B: 63 ± 8.9, C: 62 ± 9.0 488 A: 22.2 ± 5.9, B: 24.7 ± 5.3, C: 21.6 ± 4.8 Yamaguchi Single center A: Epinephrine B: No prophylaxis 204 A: 73.7 ± 8.7, B: 73.7 ± 8.3 204 A: 10.0 ± 5.8, B: 10.0 ± 5.0 Bahin Multicenter A: Combined therapy (epinephrine and succinylated gelatin injection with electrocoagulation) B: Epinephrine and succinylated gelatin injection 347 A: 66.0, B: 70.0 347 A: 39.5, B: 39.8 Park Multicenter A: Combined therapy (clipping with epinephrine) B: Mechanical therapy (clipping) 148 A: 59 ± 11, B: 60 ± 10 173 A: 17.5 ± 6.7, B: 17.2 ± 6.6

S2528 Think "Inside the Loop:" A Novel Method for Repositioning a Migrated G-J Tube

Introduction: Gastrojejunostomy tube (G-J tube) migration is common in patients requiring long term percutaneous enteral feeding. These patients often present with forceful vomiting and decreased PO intake. This case discusses a method for repositioning a migrated G-J tube using an endoloop (detachable snare device) and Resolution Clips. Case Description/Methods: A 26-year-old female with a history of cystic fibrosis (CF), chronic malnutrition requiring enteral feeds, CF-related liver disease and variceal bleeding presented with 5 days of abdominal pain and coffee ground emesis. Initially, the patient was tachycardic and vomiting intermittently. Bright red blood was visible in the emesis bag. Physical exam was notable for epigastric tenderness without peritoneal signs. The skin around the G-J tube insertion site was non-tender with no signs of infection. CT of the abdomen revealed gastrosplenic varices and appropriate positioning of the enteral tube. There was no evidence of GI perforation or obstruction. An EGD demonstrated a patent gastrostomy tube in the gastric body. The jejunal tail was coiled up against the inflamed lumen of the stomach. The suture at the tip of the tail had degraded, dislodging the tube from its original position along the jejunal wall. There were blood clots in the body of the stomach but no evidence of active bleeding. Given the suspicion that the migrated feeding tube was the cause of the patient’s symptoms, a decision was made to reposition it. An endoloop was tied around the tip of the G-J tube to serve as a substitute for the suture. A cold snare was then used to secure the endoloop and drag the tail into the jejunum. The endoloop was secured to the intestinal wall using 2 Resolution Clips. The patient’s symptoms resolved after the EGD and she was discharged in stable condition (Figure). Discussion: Migration of a G-J tube is commonly associated with severe motility disorders, such as cystic fibrosis. Oftentimes, the tube will loop inside the stomach or continue toward the esophagus. The tube itself can cause gastric outlet obstruction, leading to gastric distention, nausea and vomiting. These patients are an aspiration risk and should be initially managed with IV hydration, antiemetics, and stopping of tube feeds. In addition, it is important to assess for complications such as sepsis, hemorrhage, buried bumper, or perforation of the GI tract. If the feeding tube is patent, it is reasonable to have it repositioned based on clinical judgment and provider expertise.Figure 1.: Upper Endoscopy: A. Intact gastrostomy with a patent G-J tube present in the gastric body. The jejunal tail is coiled up in the lumen of the stomach. B. The tip of the G-J tube with surrounding trauma to the body of the stomach, characterized by edema, erythema, and inflammation. The thread at the tip of the G-J tube had degraded (yellow arrow). C. An endoloop was tied at the neck of the tip of the G-J tube (black arrow) to serve as a substitute for the suture. D. A cold snare was used to secure the endoloop (black arrow) and drag the tip of the G-J tube into the jejunum. E. The endoloop (black arrow) attached to the tip of the G-J tube was secured to the wall of the jejunum using a Resolution Clip (pink arrow).

Colonoscopic observation time as a predictor of stigmata of recent hemorrhage identification in colonic diverticular hemorrhage

Objectives The strategy of identifying stigmata of recent hemorrhage (SRH) and treating the bleeding source is important for the prevention of rebleeding in colonic diverticular hemorrhage (CDH). However, there are few known reports on SRH identification thus far. This large multicenter study evaluated factors correlated with SRH identification, including observation time during colonoscopy. Methods A total of 392 CDH cases were classified into presumptive CDH (n = 276) or definitive CDH with SRH (n = 116) on the basis of colonoscopy results. Multivariate Cox proportional hazards regression was employed to identify factors correlated with SRH identification. For the endoscopic treatment, endoscopic clips (EC), endoscopic band ligation (EBL) or endoscopic detachable snare ligation (EDSL) was performed. Results Longer observation time was significantly correlated with SRH identification in multivariate analysis (OR, 10.3 [95% CI: 3.84–27.9], p<.001). Receiver operating characteristic curve (ROC) analysis of the SRH identification rate by observation time indicated a high area under the curve (AUC) (0.79), and the threshold of the observation time was calculated at 19 min using Youden’s index. Moreover, the patients taken endoscopic hemostasis showed significantly lower early rebleeding rate than patients without endoscopic hemostasis (16.4% vs. 31.9%, p=.001), suggesting the importance of identifying SRH and treating the bleeding source for reducing the risk of recurrent bleeding. Conclusions Long-observation time correlated with SRH identification in this study, in which bowel preparation and water-jet scope and cap attachment are commonly used. This is the first known study to highlight the significance of observation time in the SRH identification rates.

Clip stopper closure method using a detachable snare in combination with ZEOCLIP for endoscopic submucosal dissection-induced mucosal defects.

Endoscopic submucosal dissection (ESD) is globally performed to treat early epithelial tumors of the gastrointestinal tract, but delayed perforation is a problematic procedure-related complication. To address this problem, closure of ESD-induced mucosal defects with a detachable snare has been reported. However, one problem is that this method usually requires some degree of skill and replacing a single-channel scope with a two-channel scope. We developed the clip stopper closure (CSC) method using a detachable snare in combination with the ZEOCLIP, which can be easily performed with a single-channel scope, for ESD-induced mucosal defects. Six consecutive cases were treated with this closure method for colonic ESD-induced mucosal defects. The median closure time was 12.5 (10-24) min, and the success rate of this procedure was 100%. Our CSC method was able to be performed in any part of the colon. In conclusion, the CSC method using a detachable snare in combination with the ZEOCLIP is a simple but promising closure technique for ESD-induced mucosal defects.

Safe removal of a synthetic paper for cake decoration that had caused a hemorrhagic rectal ulcer using a detachable snare after hemostatic treatment.

Safe removal of a synthetic paper for cake decoration that had caused a hemorrhagic rectal ulcer using a detachable snare after hemostatic treatment.

Combined over-the-scope clip and detachable snare placement as a rescue therapy for gastric ulcer rebleeding.

Combined over-the-scope clip and detachable snare placement as a rescue therapy for gastric ulcer rebleeding.

Endoscopic Detachable Snare Ligation Therapy for Colonic Diverticular Hemorrhage Improves Procedure Time Compared to Endoscopic Band Ligation.

The clipping method is widely used in endoscopic hemostasis for colonic diverticular hemorrhage. Recently, rebleeding was shown to be less common in ligation therapy than in clipping. Ligation methods include endoscopic band ligation (EBL) and endoscopic detachable snare ligation (EDSL). No studies have compared procedure times for EBL and EDSL. The present study aimed to compare EDSL and EBL in terms of procedure time. In this single-center retrospective observational cohort study, we evaluated the data of 39 patients who underwent EBL or EDSL for colonic diverticular hemorrhage. The primary and secondary outcomes measured were the total procedure time and early rebleeding rate, respectively. Among the 39 patients included in the study, 18 underwent EBL, and 21 underwent EDSL for hemostasis. The median total pro- cedure times for the EBL and EDSL groups were 50 (range, 30-80) minutes and 35 (range, 18-55) minutes, respectively, demonstrating that the total colonoscopy time was significantly shorter in the EDSL group (P < .001). The early rebleeding rate was 11.1% (2/18) in the EBL group and 4.8% (1/21) in the EDSL group (P = .246). Important improvements in procedure time were achieved in the EDSL group. Based on our results, we believe that EDSL may reduce patient and endoscopist burden.

Esophageal pyogenic granuloma resected by polypectomy using a detachable snare.

Pyogenic granuloma (PG) is a benign inflammatory vascular lesion rarely seen in the gastrointestinal tract and a possible cause of bleeding. Polypectomy using a detachable snare for esophageal PG with active bleeding is an effective treatment.

Use of a detachable snare with polyglycolic acid sheets in a simple and novel shielding method for post-endoscopic submucosal dissection ulcers.

Use of a detachable snare with polyglycolic acid sheets in a simple and novel shielding method for post-endoscopic submucosal dissection ulcers.

Efficacy of endoscopic management for anastomotic leakage after gastrectomy in patients with gastric cancer

BackgroundAnastomotic leakage (AL) after gastrectomy in gastric cancer patients is associated with high mortality rates. Various endoscopic procedures are available to manage this postoperative complication. The aim of study was to evaluate the outcome of two endoscopic modalities, clippings and stents, for the treatment of AL.Patients and methodsThere were 4916 gastric cancer patients who underwent gastrectomy between December 2007 and January 2016 at the National Cancer Center, Korea. A total of 115 patients (2.3%) developed AL. Of these, 85 patients (1.7%) received endoscopic therapy for AL and were included in this retrospective study. The endpoints were the complete leakage closure rates and risk factors associated with failure of endoscopic therapy.ResultsOf the 85 patients, 62 received endoscopic clippings (with or without detachable snares), and 23 received a stent insertion. Overall, the complete leakage closure rate was 80%, and no significant difference was found between the clipping and stent groups (79.0% vs. 82.6%, respectively; P = 0.89). The complete leakage closure rate was significantly lower in the duodenal and jejunal stump sites (60%) than esophageal sites (86.1%) and gastric sites (94.1%; P = 0.026). The multivariate analysis showed that stump leakage sites (adjusted odds ratio [aOR], 4.51; P = 0.031) and the presence of intra-abdominal abscess (aOR, 4.92; P = -0.025) were associated with unsuccessful leakage closures.ConclusionsEndoscopic therapy using clippings or stents is an effective method for the postoperative management of AL in gastric cancer patients. This therapy can be considered a primary treatment option due to its demonstrated efficacy, safety, and minimally invasive nature.

Over-the-scope clipping and detachable snare ligation as a novel combination hemostatic therapy for diverticular bleeding.

Over-the-scope clipping and detachable snare ligation as a novel combination hemostatic therapy for diverticular bleeding.

Endoscopic ischemic polypectomy for small-bowel polyps in patients with Peutz-Jeghers syndrome.

To decrease the risk of bleeding or perforation, ischemic polypectomy is performed using a detachable snare or endoclip with double-balloon endoscopy (DBE) for small-bowel polyps in patients with Peutz - Jeghers syndrome. The aim of this study was to determine the effectiveness and feasibility of ischemic polypectomy. We retrospectively reviewed patients who underwent two or more sessions of ischemic polypectomy using DBE from July 2004 to August 2017. 67 therapeutic DBEs were performed in nine patients during the study period and 352 polyps were treated. The median observation period was 34 months (range 12 - 66). There was a declining trend over time in the median number of polyps > 15 mm treated per patient first DBE session 6, second 2, third 1.5, fourth 0.5, fifth 0.5; P = 0.11, Friedman test). No patient required laparotomy due to intussusception during the study period. One patient developed mild acute pancreatitis after the procedure. Ischemic polypectomy was feasible for the control of small-bowel polyps in patients with Peutz - Jeghers syndrome.