A sessile serrated lesion (SSL) in the cecum can be difficult to resect when it is large and flat 1 , as conventional endoscopic mucosal resection (EMR) may be limited by inadequate snare positioning due to the flat morphology and indistinct margins 2 . Precutting EMR has been proposed to facilitate snare placement by performing a circumferential mucosal incision. However, this technique can be technically demanding, particularly for less experienced endoscopists, and carries a risk of perforation during mucosal incision 3 . Herein, we present a simplified technique termed pre-snaring EMR ( Video 1 ).
Pre-snaring EMR for a large sessile serrated lesion, including cold snare precutting, submucosal injection, en bloc resection, and clip closure. EMR, endoscopic mucosal resection.
Video 1
A 59-year-old woman was found to have a SSL measuring approximately 18 mm in the cecum. After delineation of the lesion margins using indigo carmine, a snare was positioned around the lesion and gradually closed without electrocautery to achieve the cold transection of the surrounding mucosa, thereby exposing the submucosal layer and creating a groove for subsequent snare placement. Submucosal injection was then performed, followed by standard EMR along the preformed groove. En bloc resection was achieved without immediate or delayed complications ( Fig. 1 ).
Fig. 1.
Stepwise demonstration of the pre-snaring EMR technique. a and b A 1.8-cm SSL in the cecum, clearly delineated after indigo carmine spraying. ( c and d Cold snaring of the lesion margin. e and f Submucosal injection with adequate lifting; visible exposure of the submucosal layer after cold snaring. g Snare resection along the preformed groove using electrocautery. h Complete resection without bleeding or perforation. i Closure of the mucosal defect with clips. j The resected specimen is stretched and pinned for the assessment of completeness. EMR, endoscopic mucosal resection.
Compared with conventional precutting EMR, this technique may simplify the procedure and lower the technical threshold, while potentially reducing the risks associated with electrosurgical incision; however, its safety and efficacy still require further validation.
Endoscopy_UCTN_Code_TTT_1AQ_2AD
Footnotes
Conflict of Interest The authors declare that they have no conflict of interest.
Contributorsʼ Statement Pan Xu: Writing – original draft, Writing – review & editing. LiYun Fu: Resources. Wan Zhou: Conceptualization, Project administration, Resources.
References
- 1.Fan C et al. Management of serrated polyps of the colon. Curr Treat Options Gastroenterol. 2018;16:182–202. doi: 10.1007/s11938-018-0176-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Yang DH et al. Endoscopic mucosal resection with circumferential mucosal incision for colorectal neoplasms: comparison with endoscopic submucosal dissection and between two endoscopists with different experiences. Clin Endosc. 2017;50:379–387. doi: 10.5946/ce.2016.058. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Yoshida N et al. Efficacy of precutting endoscopic mucosal resection with full or partial circumferential incision using a snare tip for difficult colorectal lesions. Endoscopy. 2019;51:871–876. doi: 10.1055/a-0956-6879. [DOI] [PubMed] [Google Scholar]