To date, there have been no reported perforations with cold snare polypectomy (CSP). Therefore, possible signs of damage in the muscular layer remain unknown. We report the first cases of perforation using cold snare polypectomy, when two polyps < 20 mm in size were removed. Thus we are able to describe a new sign, the "bubble sign," for checking the integrity of the submucosal and muscular layer, that can help to detect potential injury in the colonic wall when cold snare polypectomy is performed. CSP is now a highly recommended procedure for treatment of sessile adenomas up to 10 mm in size [1]. Indeed, a recent comparative study shows better results for CSP compared with hot snare polypectomy in terms of safety [2], with no perforations related to CSP described to date. After CSP, the post-polypectomy site is irrigated with a waterjet. Because the submucosal layer has been preserved, the creation of a cushion is observed. We have called this the "bubble sign" (▶ Fig. 1). However when the submucosal and muscular layer have been disrupted this cushion is missing. We present two cases of perforation with CSP (10-mm 0-Is and 15-mm 0-IIb polyps) where a snare was used that was not specifically designed for CSP (13-mm hexagonal Captivator; Boston Scientific). In both cases no bubble sign was noticed (▶ Fig. 2). Fortunately both cases were successfully managed by endoscopic clipping (Resolution Clips; Boston Scientific). The patients were admitted for observation and discharged 24 hours later without any adverse event. To date these are the first reported cases of perforation related to CSP. In fact, in two recent published meta-analyses, which included more than 1000 CSP cases, no perforations were noted [3, 4]. However, these events have allowed us to point out the usefulness of the bubble sign in assessing potential injury in the muscular layer. ▶ Fig. 1 Cold snare polypectomy (CSP) with no perforation. a, c Colonic sites after CSP. b, d "Bubble sign" after irrigation by waterjet. ▶ Fig. 2 Cold snare polypectomy (CSP) with perforation. a, c Colonic sites after CSP. b, d No "bubble sign" is seen after irrigation by waterjet.
Background: subtotal colectomy with ileorectal anastomosis (IRA) is currently the most common surgical option in young patients with familial adenomatous polyposis (FAP). However, this surgery does prevent the appearance of lesions in the rectal remnant. In these cases, the endoscopic submucosal dissection might be a feasible option. However, drawbacks such as extreme fibrosis and a difficult maneuverability in the rectal remnant make this technique rather challenging. An ESD by the pocket creation method was planned with the purpose of overcoming these handicaps. Case report: an en-bloq resection of 30 mm of the recurrent adenoma located in rectal remnant of a 42-year-old woman with FAP was successfully achieved following this approach. Two months of follow up endoscopy did not show residual adenomatous tissue. Discussion: in summary, endoscopic submucosal dissection by the pocket creation method allowed a safe and effective dissection and an en-bloc resection of this challenging polyp was achieved.
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