Basic Colonoscopic Interventions: Cold, Hot Biopsy Techniques, Submucosal Injection, Clip Application, Snare Biopsy
Colonoscopy for the early detection of premalignant lesions of the colon and rectum has changed the natural history of colorectal cancer since its inception in the mid 1900s. The prevention of colorectal cancer by removal of adenomatous polyps (polypectomy) via colonoscopy is one of the greatest public health innovations in recent history. Programs such as the “80% by 2018” initiative have been successful in promoting age-appropriate colorectal cancer screening across the United States, and worldwide. Advances in flexible endoscopes and devices used for polypectomy have allowed for improvement in the sensitivity of colonoscopy in the detection of adenomatous polyps as well as improved safety. In this chapter, we will discuss various basic colonoscopic interventions, including hot and cold biopsy techniques, submucosal injection of substances (for tattooing and for facilitating polypectomy), clip application, and snare polypectomy.
KeywordsColonoscopy Polypectomy Endoscopic snare polypectomy Colon biopsy Difficult polypectomy, submucosal injection, saline lift-assisted polypectomy
Endoscopic mucosal resection
Endoscopic submucosal dissection
National Comprehensive Cancer Network
Cold biopsy : This technique is useful for removing small polyps and to biopsy larger lesions. Mucosal biopsies are also commonly performed using this technique. The authors advocate for routine use of Jumbo forceps, as they can accommodate larger tissue specimens and may help achieve complete polypectomy (MOV 30291 kb)
Submucosal injection : A specialized endoscopic needle can be used to inject substances into the submucosal plane, lifting a lesion off of the submucosa or musclaris propria for endoscopic excision. A variety of substances can be used for this purpose (MOV 79363 kb)
Tattooing: Endoscopic placement of a substance in the submucosal plane using an endoscopic needle can be performed to mark the area for future identification. A permanent, colored substance such as India ink or methylene blue can be used for this purpose. The ink should be visible during repeat endoscopic evaluation. Also, the tattoo should be able to be identified on the serosal surface as well for identification during surgical resection (MOV 70218 kb)
Clip : This video demonstrates endoscopic clip placement during colonoscopy. Clips can be useful to help achieve hemostasis after polypectomy or other intervention, and also in attempts to close perforations caused during endoscopy (MOV 61832 kb)
Snare polypectomy : This technique is useful for removing larger polyps that may not be completely removed using biopsy forceps. A thin wire is passed around the base of the polyp and tightened, amputating the lesion. This can be done “cold”—without the application of cautery, or “hot” using monopolar cautery. Injection of a substance beneath the lesion to be removed can help facilitate placement of the snare to ensure that the entire lesion is removed (MOV 56989 kb)
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