Snare Removal Research Articles

Addressing the Southeast Asian snaring crisis: Impact of 11 years of snare removal in a biodiversity hotspot

AbstractUnsustainable snaring is causing biodiversity declines across tropical protected areas, resulting in species extinctions and jeopardizing the health of forest ecosystems. Here, we used 11 years of ranger‐collected data to assess the impact of intensive snare removal on snaring levels in two protected areas in Viet Nam. Snare removal resulted in significant declines in snare occupancy (36.9, 95% Bayesian credible interval [4.6, 59.0] reduction in percent area occupied), but snaring levels nonetheless remained high (31.4, [23.6, 40.8] percent area occupied), and came with a substantial financial cost. Our results indicate that snare removal remains an important component of efforts to protect tropical protected areas but by itself is likely insufficient to address this threat. To stop snaring in protected areas, a multifaceted approach will be necessary that combines short‐term reactive snare removal with long‐term proactive programs that address the underlying drivers behind snaring.

Habitat accessibility and snares impact large cats and their prey in Northeast Tiger and Leopard National Park, China

Snares have become a widespread hunting technique, with their indiscriminate nature jeopardizing terrestrial large carnivores. Since the lack of reliable data on snare distribution hampers an accurate evaluation of the potential risk. Continuous winter SMART (the Spatial Monitoring and Reporting Tool) patrols have operated in the Amur tiger (Panthera tigris altaica) and Amur leopard (Panthera pardus orientalis) ranges in northeast China from 2013 to 2020 to record wildlife occurrences and remove snares. Our research aimed to assess the snares threat pose in the Amur tiger range and whether snare removal benefited roe deer (Capreolus pygargus) and wild boar (Sus scrofa) recovery. We modeled the spatial distribution of Amur tigers, Amur leopards, and prey species, comparing their distributions before and after anti-poaching measures. We also assessed the overlap between Amur tigers, Amur leopards, and snare locations. Additionally, we used the MaxEnt model to predict snare distribution, and then we analyzed the overlap of snares with species at different periods between 2013 and 2015 and 2018–2020.Our results showed that the probability of occurrence of ungulates increased significantly around roads after snares were removed. Furthermore, we found that Amur tigers and Amur leopards distribution overlapped with snare locations suggesting that snares pose a serious risk to these non-target species. The overlap between snares and species has the same trend as the growing with species distribution, and the least significant increase is in DHZ-XNC.Removing snares not only aids target game species but also protects sympatric large carnivores.

Wired Snare and Negus Artery Ligation for Securing Lower Pole Tonsillar Removal during Cold Steel Tonsillectomy: A Comparative Study

Background: Tonsillectomy is one of the most commonly practised surgeries in general and otolaryngology. Bleeding tonsillar lower pole, primarily pain and tonsillar remnant are common complications of this operation.
 
 Objectives: To assess and compare the effectiveness of wired snare removal of the inferior tonsillar pole with negus artery ligaturisation technique regarding bleeding, pain, operative time, and the tonsillar remnant in cold dissection tonsillectomy.
 
 Patients and Methods: This hospital-based, prospective, comparative study was conducted on 200 patients (400 tonsils) that underwent a tonsillectomy in Sulaimani Teaching Hospital and Shorsh Teaching Hospital from April 2021 to February 2022. On one side, the tonsil's inferior pole was removed by silk using negus artery ligaturisation, while the other lower pole tonsil of the same patient was crushed by wired eves snare. Patients followed up on the 4th, 7th day, and 8th weeks postoperative for bleeding, pain, fever, and tonsillar remnant.
 
 Results: Most patients were aged 5-10 years (48.5%) and males (56%). The mean±SD of surgical time for wired snaring was significantly (p=0.000) shorter (6.04±0.47 minutes) than that of artery ligation (7.0±1.55 minutes). The tonsillar remnant occurred mainly with ligation, while bleeding more commonly occurred on the snare side (p=0.048).
 
 Conclusions: Lower tonsillar pole negus ligation removal was associated with less bleeding and pain. However, it is more time-consuming operatively, with more tonsillar remnant occurrence than wired snare removal of the lower pole.

Use of etorphine hydrochloride for immobilisation of Nubian giraffe for wire snare removal: a retrospective study

Use of etorphine hydrochloride for immobilisation of Nubian giraffe for wire snare removal: a retrospective study

Short-term toll-like receptor 9 inhibition leads to left ventricular wall thinning after myocardial infarction.

Ischaemia-reperfusion injury (IRI) following myocardial infarction remains a challenging topic in acute cardiac care and consecutively arising heart failure represents a severe long-term consequence. The extent of neutrophil infiltration and neutrophil-mediated cellular damage are thought to be aggravating factors enhancing primary tissue injury. Toll-like receptor 9 was found to be involved in neutrophil activation as well as chemotaxis and may represent a target in modulating IRI, aspects we aimed to illuminate by pharmacological inhibition of the receptor. Forty-nine male adult Sprague-Dawley rats were used. IRI was induced by occlusion of the left coronary artery and subsequent snare removal after 30min. Oligonucleotide (ODN) 2088, a toll-like receptor 9 (TLR9) antagonist, control-ODN, or DNase, were administered at the time of reperfusion and over 24h via a mini-osmotic pump. The hearts were harvested 24h or 4weeks after left coronary artery occlusion and immunohistochemical staining was performed. Echocardiography was done after 1 and 4weeks to determine ventricular function. Inhibition of TLR9 by ODN 2088 led to left ventricular wall thinning (P=0.003) in association with drastically enhanced neutrophil infiltration (P=0.005) and increased markers of tissue damage. Additionally, an up-regulation of the chemotactic receptor CXCR2 (P=0.046) was found after TLR9 inhibition. No such effects were observed in control-ODN or DNase-treated animals. We did not observe changes in monocyte content or subset distribution, hinting towards neutrophils as the primary mediators of the exerted tissue injury. Our data indicate a TLR9-dependent, negative regulation of neutrophil infiltration. Blockage of TLR9 appears to prevent the down-regulation of CXCR2, followed by an uncontrolled migration of neutrophils towards the area of infarction and the exertion of disproportional tissue injury resulting in potential aneurysm formation. In comparison with previous studies conducted in TLR-/- mice, we deliberately chose a transient pharmacological inhibition of TLR9 to highlight effects occurring in the first 24h following IRI.

The “reverse vessel sign” mandating endoscopic hemostasis after cold snare removal of a large adherent clot in lower GI bleeding

The “reverse vessel sign” mandating endoscopic hemostasis after cold snare removal of a large adherent clot in lower GI bleeding

Advances in ureteral stent technology.

Ureteral stents are an invaluable tool for urologists but suffer from several drawbacks, including: limited durability due to stent encrustation, significant morbidity from bothersome urinary symptoms, pain and infection, risk of the forgotten stent and costly removal. This review highlights key advances in ureteral stent technology that seek to address these issues. Over the past 2 years clinical trials have brought ureteral stent technology aimed to reduce stent-associated morbidity closer to clinical application. Stent material and changes to stent design show promise in improving patient tolerability without increasing complications. Low-tech innovations such as magnetic and catheter snare removal may quickly reduce costs. Radical advances such as biodegradable stent materials remain in preclinical models but show promise for eliminating the need for stent removal. The ideal ureteral stent does not currently exist in clinical practice. This review highlights key studies that have advanced ureteral stent technology in the past 2 years.

Prospective evaluation of the effectiveness of colonoscopic polyp resection

Background: Colon cancer incidence is on the rise and despite having undergone a colonoscopy to screen and remove all visible polyps as a preventive measure, nearly 1 in 110 patients will develop colon cancer within 3 years. The three main possible explanations for this are missing polyps, incompletely removed polyps, or rapidly growing tumors. Objective: To determine the proportion of colonic polyps ≤ 3 cm in size that show evidence of residual polyp tissue following colonoscopy and polypectomy. Methods: Patients who presented for colonoscopy at a community center were invited to participate in this study. Those who had confirmed adenoma were invited to repeat the procedure in 2 to 6 months with biopsies at the resection site to check for the presence of residual polyp tissue. Exclusion criteria included the absence of adenoma in the resected lesion, contraindication to polypectomy or follow-up colonoscopy, refusal to participate in follow-up examination, and other conditions increasing colon cancer risk. If polyps between 5 mm and 30 mm were found, the endoscopist resected them using the hot snare polypectomy technique or endoscopic mucosal resection (EMR). Results: Ninety-one patients completed the study protocol, with 105 lesions being studied. The second procedure was performed between 2 and 24 months. All analyzed lesions were adenoma, and three of them were associated with intramucosal adenocarcinoma. Others included 60 tubular lesions, 37 tubulovillous lesions, and 5 serrated lesions. Thirty-two lesions were flat and were removed by EMR; polypectomy was performed for 73 lesions. There was no residual tissue in the polypectomy group. The EMR group presented three cases of incomplete resection without adenocarcinomas. Conclusion: Our study showed that flat lesions might be an important cause of incomplete resection. In addition, we documented the complete resection of pedunculated lesions in all studied patients. This study provides more evidence to validate the empirical perception in the medical field that assumes the complete resection of pedunculated polyps. Therefore, we suggest that patients who undergo snare removal of pedunculated polyps should follow the regular protocol for colon cancer screening, with colonoscopy every 5 to 10 years. Meanwhile, the surveillance scheme should be reviewed for patients who undergo removal of flat lesions smaller than 30 mm.

S1721 A Rare Finding in the Colon: Undifferentiated Pleomorphic Sarcoma

Introduction: Undifferentiated pleomorphic sarcoma (UPS) is a rare and incompletely understood condition that commonly appears in the extremities and retroperitoneum. Involvement of the bone and digestive organs is rare. We describe the case of a 78-year-old man who was incidentally diagnosed with UPS of the colon after workup of uncontrolled lower back pain. Case Description/Methods: A 78-year-old man with extensive tobacco use initially presented to his primary care provider with intractable back pain and a 10lb weight loss. His exam was notable for paraspinal muscle tenderness, but otherwise unremarkable. A subsequent computed tomography (CT) abdomen and pelvis was negative. Given these findings and a suspicion for a musculoskeletal diagnosis, he was treated conservatively. Despite initial therapies, he experienced no clinical improvement. Further imaging with magnetic resonance imaging (MRI) of the spine showed a pathologic fracture of T12 and metastatic vertebral disease causing spinal cord compression. A follow up CT showed pulmonary nodules at the lung bases also concerning for metastatic disease. A set of follow up labs showed an elevated carcinoembryonic antigen (CEA) level of 7.4 ng/mL. He was referred to gastroenterology for expedited colonoscopy and malignancy workup in the setting of an elevated CEA. Colonoscopy revealed one 5-9 mm sessile cecal polyp. Cold snare removal of the polyp was unsuccessful because of resistance and the firmness of the lesion. A biopsy was obtained instead. While awaiting pathology, he underwent decompressive laminectomy and spinal stabilization with tumor biopsy of T12 for further neoplastic workup. Pathology of both the cecal polyp and the T12 intervertebral disc revealed high-grade UPS. Given the extent of disease, palliative radiation and chemotherapy were offered however the patient passed away shortly thereafter. Discussion: UPS is a rare and aggressive neoplasm; diagnosis is challenging because patients are often asymptomatic unless there is nerve involvement and because of its rapid development. Our patient presented with back pain which was attributed to a musculoskeletal ailment. Upon further investigation with a colonoscopy and biopsy, UPS was discovered. Although gastrointestinal metastasis is rare, it is important to consider a broad differential when a benign appearing polyp cannot be excised in a standard fashion.

Density trends of wild felids in northern Laos

Determining the density trends of a guild of species can help illuminate their interactions, and the impacts that humans might have on them. We estimated the density trends from 2013 to 2017 of the clouded leopard Neofelis nebulosa, leopard cat Prionailurus bengalensis and marbled cat Pardofelis marmorata in Nam Et—Phou Louey National Park (NEPL), Laos, using camera trap data and spatial capture-recapture models. Mean (± SD) density estimates (individuals/100 km2) for all years were 1.77 ± 0.30 for clouded leopard, 1.50 ± 0.30 for leopard cat, and 3.80 ± 0.70 for marbled cat. There was a declining trend in density across the study years for all three species, with a ≥ 90% probability of decline for clouded leopard and leopard cat and an 83% probability of decline for marbled cat. There was no evidence that mesopredator release occurred as a result of tiger (Panthera tigris) and leopard (P. pardus) extirpations. We believe that snaring, the factor that led to the extirpation of tiger and leopard in NEPL, is now contributing to the decline of smaller felids, to an extent that over-rides any potential effects of mesopredator release on their densities and interactions. We recommend that the NEPL managers implement a more systematic and intensified snare removal program, in concert with extensive community outreach and engagement of local people to prevent the setting of snares. These actions might be the only hope for saving the remaining members of the felid community in NEPL.

S0196 The Costs of Guideline Adherence: A Retrospective Evaluation of the Economic Impact of Snare vs Forceps Removal of Diminutive Colon Polyps in an Academic Medical Center

S0196 The Costs of Guideline Adherence: A Retrospective Evaluation of the Economic Impact of Snare vs Forceps Removal of Diminutive Colon Polyps in an Academic Medical Center

Retained gastrostomy bumper resulting in esophageal fistula and spinal osteomyelitis

Abstract Background We report a case of spinal osteomyelitis and fistulous tract between the esophagus and prevertebral soft tissues secondary to an esophageal foreign body. This resulted from a retained gastrostomy bumper that broke on removal of the tube seven years earlier. Case presentation A 9-year-old male with Troyer Syndrome and developmental delay presented to his pediatrician with the refusal to bear weight and new onset torticollis, and was referred to our institution for further evaluation. He was admitted for further workup due to concern for a neurological process. Imaging revealed osteomyelitis of T3/T4 and inflammatory changes in the posterior mediastinum with possible communication with the esophagus. His gastrostomy tube (GT) was converted to a gastrojejunal tube (GJT) for post-pyloric feeding. He acutely worsened after this procedure, and further radiographic imaging revealed a retained foreign body in the esophagus. An upper endoscopy was subsequently performed with snare removal of the object, identified as the bumper of a previous gastrostomy tube. This esophageal foreign body caused esophageal erosion leading to creation of a fistulous tract with nidus for infection spread posteriorly. The patient underwent prolonged treatment for the infection, with improvement in his presenting symptoms, and eventually resumed gastrostomy feeding. Conclusion Retained foreign body following gastrostomy removal, while typically does not warrant further investigation, may present with significant sequelae if retained especially in children with developmental delay and feeding difficulties.

Rates of Incomplete Resection of 1- to 20-mm Colorectal Polyps: A Systematic Review and Meta-Analysis

Incomplete resection of neoplastic colorectal polyps can result in postcolonoscopy colorectal cancer. We performed a systematic review and meta-analysis to determine the incomplete resection rate (IRR) of colorectal polyps and associated factors. We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL to identify full-text articles that reported IRRs of polyps 1 to 20 mm, published until March 2019. Exclusion criteria were studies of inflammatory bowel disease cohorts, referrals for difficult polypectomy, polyp sizes larger than 20 mm, and endoscopic submucosal resection and/or dissection as polypectomy approaches. IRRs were calculated based on findings from biopsies taken at polypectomy sites or assessments of margins of resected polyps. The primary outcome was IRR for snare removal of polyps 1 to 20 mm. Secondary outcomes included IRR for polyps 1 to 10 mm and 10 to 20 mm, IRR for hot and cold snare removal of polyps 1 to 10 mm and 10 to 20 mm, IRR of snare removal with or without submucosal injection, and IRR for forceps and cold snare removal of polyps 1 to 5 mm. We identified 6148 reports and used 32 studies, with a total of 9282 polyps, in our quantitative analysis. The IRR for snare removal of polyps 1 to 20 mm was 13.8% (95% confidence interval [CI] 10.3-17.3; 13 studies, 5128 polypectomies). IRRs were 15.9% for snare removal of polyps 1 to 10 mm (95% CI 9.6-22.1; 9 studies, 2531 polypectomies) and 20.8% for snare removal of polyps 10 to 20 mm (95% CI 12.9-28.8; 6 studies, 412 polypectomies). The IRR for hot snare removal of polyps 1 to 10 mm was 14.2% (95% CI 5.2-23.2) vs 17.3% for cold snare polypectomy (95% CI 14.3‒20.3). The IRR for forceps removal of polyps 1 to 5 mm was 9.9% (95% CI 7.1-13.0) vs 4.4% for snare polypectomy (95% CI 2.9-6.1). In a systematic review and meta-analysis, we found that colorectal polyps 1 to 20 mm are frequently incompletely resected, and that risk increases for polyps 10 mm or larger. There is no difference in IRRs of cold vs hot snares for polyps 1 to 10 mm. Snare polypectomy should be used over forceps for polyps 1 to 5 mm.

Development and validation of a video-based cold snare polypectomy assessment tool (with videos)

Polyps<1 cm are the most commonly found polyps during colonoscopy. Cold snare removal is preferred given the significantly higher rate of incomplete resection associated with piecemeal biopsy forceps resection. There are currently no standardized tools to assess competence in cold snare polypectomy. This study aimed to develop and validate a cold snare polypectomy assessment tool (CSPAT). Experts in cold snare polypectomy used a Delphi method to develop the CSPAT. Metrics with a greater than 85% agreement as being "important" or "very important" were included in the CSPAT. The tool included evaluation of polyp inspection, positioning, appropriate ensnarement of tissue to ensure a rim of normal tissue, tissue retrieval, and postpolypectomy site inspection. Experts in cold snare polypectomy used the CSPAT to evaluate preselected videos that were previously evaluated using the Direct Observation of Polypectomy Skills (DOPyS) tool. Interobserver agreement was evaluated. CSPAT scores were compared with DOPyS scores to assess content validity. Sixteen experts developed the 12-item CSPAT, and 13 experts reviewed 55 videos. There was a moderate degree of agreement in 10 metrics (κ= .52-.59) and a substantial degree of agreement (κ= .61-.63) in the other 2. There was a strong correlation between the mean of individual metrics 1 to 12 compared with the global competence assessment (ρ= .88, P< .001). There was a moderate correlation between the average overall DOPyS score and the overall CSPAT competence score (ρ= .56, P< .001). We have developed and validated a customized CSPAT that can be easily applied to video-based assessments to assess competence in training and among practicing endoscopists.

Cold snare polypectomy: Indications, devices, techniques, outcomes and future.

Colonoscopy has been shown to reduce the risk of colon cancer by enabling the removal of precancerous lesions. Although cold snare and hot snare polypectomy have similar retrieval rates and complete resection rates, rates of delayed bleeding tend to be lower with cold snare polypectomy than with hot snare polypectomy, especially for patients taking antithrombotic agents. However, among cold snares there may be differences in terms of the completeness of polyp excision, as complete removal appears more likely with thin-wire dedicated cold snares compared to the traditional, thick-wire cold snares. Cold snare polypectomy may be especially well suited for use in patients taking antithrombotic agents, due to its minimal risk of delayed bleeding. Histological analyses suggest that cold snare polypectomy causes less damage to blood vessels in the submucosal layers, which results in a reduced incidence of hemorrhage compared to hot snare polypectomy. However, cold snare removal of small polyps may result in fragmentation of small specimens during collection and concerns as to whether the resection is complete. An endoscopy biomarker of effective cold snare polypectomy technique is needed to ensure complete removal of non-pedunculated colorectal polyps ≤10mm. Future uses of cold snare polypectomy may include piecemeal removal of sessile serrated adenoma/polyp lesions >10mm. Currently, cold snare polypectomy should be considered a primary method for colorectal polyps of less than 10mm, especially those in the 4- to 10-mm range.

Left Mainstem Bronchus Glomus Tumor of Uncertain Malignant Potential Managed by Repeated Bronchoscopic Ablations

SESSION TITLE: Metastatic and Other Primary Lung Tumors SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Glomus tumors (GTs) are rare neoplasms arising from the modified smooth muscle cells surrounding arteriovenous anastomosis. Due to sparse or absent glomus bodies in the visceral organs, extracutaneous presentation of GTs are rare. We present a case of a man with left main bronchus glomus tumor managed with serial bronchoscopies. CASE PRESENTATION: A 53 year old man presented to the emergency department with daily episodes of hemoptysis. Computerized tomography evidenced a 11 x 7 mm lesion in the left distal carina and PET-CT did not detect areas of hypermetabolic activity. Bronchoscopy revealed a lobulated endobronchial lesion on the anterior wall of the left mainstem bronchus. Biopsy specimen was analyzed at the Joint Pathology Center in Maryland which showed: epithelioid cells with abundant eosinophilic cytoplasm, sharp cell borders arranged in sheaths, focal atypia with neoplastic cells demonstrating vesicular chromatin, all suggestive of glomus tumor. On repeat bronchoscopy, snare removal of a 1.5 cm smooth pedunculated lesion and cryoablation of the stump was performed. EBUS inspection showed submucosal extension (<1 cm) with no invasion of the external wall of the trachea or surrounding lymph nodes or vessels. Electron microscopy confirmed it as a glomus tumor with borderline mitosis figure of 5/50 on HPF. The specimen was SMA and vimentin positive, had increased KI-67 activity and unknown malignant potential with positive margins. Follow up endoscopy revealed a lobulated lesion with necrosis on the anterior wall of the left mainstem. Patient underwent serial cryoablation, with repeat surveillance showing a 0.5 cm x 0.3 cm fungating lesion and no mass was visualized on the fourth endoscopy. DISCUSSION: Contrary to our case, most GTs in the airway occur in the posterior wall, were mucous glands and vessels are numerous. The diagnosis of malignant GTs is reserved for tumors having: a size of >2 cm and subfascial or visceral location, atypical mitotic figures or marked nuclear atypia. This case had unknown malignancy potential due to the presence of mitotic activity and cellular atypia but lack of other criteria. Of reported cases, only 3 were identified as of unknown malignant potential. Historically, GTs were treated by surgical resection. Only 15 of the 49 described cases were treated endoscopically. Our case did not show recurrence at follow up, previous reports described normal findings after 6 years of surgical resection. CONCLUSIONS: In patients with tracheal glomus tumors who are poor surgical candidates or are not willing to undergo surgery, bronchoscopy tumor removal can be a feasible alternative. Reference #1: Fernandez-Bussy, S. Concomitant tracheal and subcutaneous glomus tumor: Case report and review. Respir Med Case Rep, 2015, 16, 81-5. Reference #2: Folpe AL. Glomus tumors. In: Fletcher CDM, Unni KK, Mertens F, editors. WHO classification of tumors: pathology and genetics of tumors of soft tissue and bone. Lyon (France): IARC Press; 2002. pp. 136-37. DISCLOSURE: The following authors have nothing to disclose: Felix Reyes, Michael Cutaia, Mohammad Al-Ajam, Fidelina De Soto Lapaix No Product/Research Disclosure Information

Rescue therapy of a refractory rectal variceal bleeding in a cirrhotic patient by Linton-Nachlas tube and TIPS implantation in combination with variceal embolization

Background Transjugular intrahepatic portosystemic shunt (TIPS) is considered the gold standard for treatment of gastrointestinal variceal bleeding refractory to endoscopic therapy in patients with portal hypertension. Clinically relevant hemorrhage from rectal varices is less frequent than from other sources, and the therapeutic role of TIPS is still ambiguous. Case report A 57-year-old female patient was referred to us in December 2015 with severe signs of decompensated alcohol-induced liver cirrhosis. During hospitalization, she presented with recurrent hematochezia from rectal varices following electrosurgical snare removal of a rectal adenoma. Endoscopic treatment with hemoclips, epinephrine and fibrin glue injections, and thermocoagulation failed to permanently stop the bleeding. Recurrent hemorrhage led to a further deterioration of liver function and clinical status of the patient. After a total of 3 endoscopic treatment attempts, hemostasis was achieved by transanal placement of a Linton-Nachlas balloon tube. Additionally, TIPS implantation with embolization of the rectal varices was performed successfully 24 hours after tube insertion, resulting in reduction of the portosystemic pressure gradient from 24 to 12 mmHg. Subsequently, the patient recovered clinically, hemopressin and catecholamine treatment was discontinued, and liver function test as well as serum hemoglobin levels improved. No further blood transfusions were required. Conclusion In this patient, rescue therapy with balloon compression and TIPS implantation in combination with variceal embolization in a cirrhotic patient with refractory rectal variceal bleeding was effective. To our knowledge, it is the first description of this specific therapeutic approach.

Avulsion is superior to argon plasma coagulation for treatment ofvisible residual neoplasia during EMR of colorectal polyps (withvideos).

EMR is used widely for treatment of nonpedunculated colorectal adenomas≥ 2 cm. Recurrence at the resection site occurs in 10% to 30% of cases. Records of consecutive patients referred for endoscopic resection over a 4-year period were reviewed retrospectively. In the first part of the study period, our routine practice was to use argon plasma coagulation (APC) to treat all visible residual neoplasia after exhaustive attempts at snare resection during EMR. In the second part of the study period, we changed our practice to use avulsion to treat all visible residual neoplasia after exhaustive attempts at snare resection during EMR. We analyzed the effect of this change in practice on recurrence rates after EMR. Two hundred twenty-three resected lesions were analyzed. Fifty-nine (26%) were treated with en-bloc EMR, 55 (25%) by piecemeal EMR with complete snare removal of all visible neoplasia, 63 (28%) by piecemeal EMR with APC of visible residual neoplasia, and 46 (21%) by piecemeal EMR with avulsion of visible residual neoplasia. There was no significant difference in adverse event rates among the 4 groups. The recurrence rates on follow-up colonoscopy were 4.2%, 3.0%, 59.3%, and 10.3%, respectively. The recurrence rate for patients treated with avulsion was significantly lower than for those treated with APC (odds ratio, .079; P< .001). Multivariate analysis demonstrated that use of avulsion instead of APC was a significant predictor of no recurrence. After exhaustive attempts at snare resection during EMR, avulsion is superior to APC for treatment of residual visible neoplasia. Compared with APC, avulsion significantly decreases the recurrence rate without significantly increasing the risk of the procedure.

Modified snare removal of a retained lead

Article history: Received 24 October 2015 Accepted 26 October 2015 Available online 9 November 2015 tation the old one was attempted to be removed manually by performing simple traction. The proximal portion of the lead, however, was torn and retained. Two and a half years after the second procedure the pulse generator was explanted and proximally cut leads were left in the pocket because of pocket infection. Just before being referred to our center some retained leads protrude from the pectoral skin. Nonpowered extraction tools, locking stylets (Lead Locking Device® EZ,

Loop Snare Removal of Pigtail Catheter Fragment From the Pleural Space

Loop Snare Removal of Pigtail Catheter Fragment From the Pleural Space