00:00:01: Somehow it is paradoxical, you would think that hot snares are safer than cold snares for those patients and they're the other way around.

00:00:10: Welcome to a live recording of the ESGE podcast Indoscopy Unplugged!

00:00:16: Join us each month to hear the latest from European experts on where we'll discuss relevant clinical topics... ...and provide tips & tricks, practical scientific evidence….

00:00:28: …and piles of wisdom to inform your Indoscopy practice.

00:00:32: So please subscribe wherever you get your podcasts, and join us as we advance GI endoscopy care.

00:00:39: Hello everyone!

00:00:40: And welcome to episode seven of ESG's podcast Endoscopy Unplugged.

00:00:46: today We have a very special episode for you because we are recording live on the spotlight stage at ESG days twenty-twenty six in Milan Italy.

00:00:55: As you know my name is Zion Grolnik past president of the SGE, and I'm your host.

00:01:01: Today's podcast is titled Snare Smart Cold & Hot Techniques for Colon Polyperies Section And my guest is Professor Maria Palise Head of Endoscopy at The Hospital Clinic Of Barcelona An Associate Professor At The University Of Barcelona.

00:01:18: Welcome Maria to the Podcast.

00:01:20: Hi Hello

00:01:21: It's Great To Have You Here.

00:01:23: It's really great and here in the spotlight even more.

00:01:26: Exactly, we're having a great time here at Milan at ESG days.

00:01:29: it has been fantastic.

00:01:31: over six thousand participants here.

00:01:34: its unbelievable

00:01:35: Unbelievable!

00:01:36: And everything is so lively.

00:01:38: there are so much activity everywhere.

00:01:40: Absolutely So listen before you get into this.

00:01:43: how did your endoscopy?

00:01:46: That's nice.

00:01:47: I think endoscopy provides me the exact balance that they needed between clinics and surgery, let say So.

00:01:55: I felt that Endoscopy was perfect because you could solve things very quick And i loved it.

00:02:02: And you did some advanced training in Endoscopy, right?

00:02:05: Yes.

00:02:05: I first started doing

00:02:07: U.S.,

00:02:07: this was my

00:02:08: Ph.D.A.,

00:02:08: it wasn't in the US which...I didn't know that really!

00:02:13: Which i loved it.

00:02:14: and then..i had a terrible illness.

00:02:17: ..and then i was disabled ,a little bit physically disabled Really?

00:02:22: yes so i needed to not do too much endoscopy okay.

00:02:25: ...and when screening Program of colorectal cancer program was starting so in

00:02:31: Barcelona

00:02:32: and everywhere a little bit like In two thousand nine eight,

00:02:36: okay?

00:02:37: And I thought it was the perfect opportunity to put together my endoscopic knowledge in other things that were not so physically demanding.

00:02:46: That's why I moved more towards high risk conditions, screening and polypectomy

00:02:53: And

00:02:53: after a few years... ...I went to Australia where i was a fellow with Michael Berg and there.. ..I could learn very much how manage large lesions and EMRs.

00:03:06: Well today we're going to talk about cold and hot snare for colon polyp.

00:03:12: So let's get into this, if you are looking sort of at a big picture how do you decide when your doing the colonoscopy?

00:03:19: How does it decide whether a polyp is appropriate for cold snare versus hot snare resection?

00:03:26: So we think that now things are quite clear and there is a very easy message.

00:03:30: Most of the polyps will be removed with cold snare, so Cold Snare is our best ally And you have to have it all the time.

00:03:39: But basically for polyps that are smaller than ten millimeters There's no doubt

00:03:43: Smaller then?

00:03:43: Ten

00:03:44: Okay

00:03:45: that there is no doubt when it's to ten-to-twenty.

00:03:48: here, a little bit more you have to do better choice and then we'll also look at pedunculated polyps.

00:03:55: Here if they are really small sometimes very small pedunculated polyps I will continue doing cold snaring.

00:04:01: but if the area larger this wouldn't be good choice.

00:04:05: because

00:04:05: of the vasculature within stock.

00:04:07: exactly

00:04:08: okay.

00:04:09: so what would get in order for that?

00:04:11: just a little for everything or where, because I still see people will be using biopsy forceps.

00:04:19: No!

00:04:20: Okay exactly that's what i want you to talk about.

00:04:23: so Biopsy Forceps Where are we today?

00:04:25: Should We Be getting rid of those as part of polypectomy?

00:04:28: No, I don't think we have to be absolute with anything.

00:04:31: We need many tools and know that some situations needs different tools.

00:04:36: It is true for very small polyps like less than three millimeters.

00:04:40: sometimes they are in a place where it's really difficult to have good stability And you NEED to use your biopsy forceps.

00:04:48: Also when you have a recurrence on a very fibrotic area Sometimes the biopsy forceps can also help.

00:04:54: so much.

00:04:55: So i would never say that it's an absolute thing, but for most of the cases you should be using cold snaring.

00:05:03: Okay so let me ask a little bit more.

00:05:06: dive a little deeper in terms of sizing.

00:05:09: I'm doing a colonoscopy.

00:05:10: i see a sessile polyp maybe on the right colon and im estimating at maybe twelve or fifteen millimeters in size.

00:05:19: It looks to me by characterization.

00:05:21: this is a tubular adenoma there nothing special about.

00:05:25: do have any problems taking.

00:05:28: I have to say that they go too cold more and more because of the safety part.

00:05:35: But it is true when lesions get a little bit larger, like you were saying their risk for containing cancer increases but still very low.

00:05:44: So here, if you think that the lesion can have cancer or even a little bit of suspicion.

00:05:49: You shouldn't be removing it with cold-sneering because cold-snaring... ...the plane of resection is musculatis mucosa.

00:05:57: It's more shallow?

00:05:58: Yes so then there are risks not doing complete resection and in those cases we should elevate the lesions to use diathermy which will help us go deeper.

00:06:09: Okay, so you are... but what about if I would just to inject underneath and take it out with cold still?

00:06:15: It's the same because when you cut through with this snare we see that most of times a plane will be muscular mucosa or the laminopropia.

00:06:27: So you'll only be in the mucosal in twenty percent cases

00:06:31: Okay.

00:06:32: So walk us through sort of like a step-by-step technique, what's the optimal cold snare polypectomy?

00:06:40: The first thing as always is that you need to be very stable and have it in good position which

00:06:46: is where

00:06:47: this is at six o'clock.

00:06:51: And this is important because I think that coalesce nearing small polyps, it's the perfect scenario to train yourself.

00:06:57: To do good tip control.

00:06:59: sometimes It's much difficult to remove a very tiny polyp than a large one and you would really feel like you are stupid.

00:07:10: You see these small thing?

00:07:11: That he's bumping from side-to-the other.

00:07:13: but it's The Perfect Scenario to say what.

00:07:15: if i do that properly then I will be able to remove whatever even with an ESD.

00:07:22: So, we have to think that it is a big challenge!

00:07:25: Alright so let me challenge you...so lets say find the small polyp four or five, six millimeters.

00:07:30: You're going to take it out with your cold snare but its located up at the twelve o'clock position.

00:07:35: are you rotating the scope?

00:07:36: Are you moving a patient?

00:07:38: what do you do?

00:07:38: So first thing is that we need straight scopes.

00:07:42: so if u have a straight scope then you will have good control.

00:07:45: sometimes you don't use a straight Scope.

00:07:47: First thing try and use a Straight Scope.

00:07:49: Use

00:07:49: your loops

00:07:50: Reduce Your Loops And make sure That The Movements With The Scope Have A Translation One-to-One To The Tip Of The Scopes.

00:07:58: the other way that you will know is to take your right hand out of it and see if its really rigid or floppy.

00:08:09: If its floppy, everything's alright!

00:08:11: If its very rigid probably then you don't have a straight scope.

00:08:14: The next thing we can look at how far away from the anal verge in order for us not having a straight scope.

00:08:26: Okay, and then once you have it You will turn it as I would say that you will be able to put the polyp wherever you want.

00:08:32: So your gonna rotate your scope to bring that pod to the six o'clock position

00:08:36: exactly.

00:08:37: Do sometimes need to have your nurse or Does a trainee hold your scope in place?

00:08:42: No, sometimes it is some pressure on the belly because there's looping and you need that pressure to make sure you can have that.

00:08:50: Sometimes you need to roll the patient And sometime its true.

00:08:53: if there are positions where you really cant do so then you'll be able to do as best as possible.

00:08:58: But the optimal position at least of positioning that polyp is at the six o'clock position.

00:09:04: Next step what will we do?

00:09:04: You've got a six o clock position.

00:09:06: Next step, it is important the snare because if you are going to remove a tiny polyp three millimeters five millimeters and You're using a fifty millimeter snare.

00:09:15: It's not going to work.

00:09:16: So you need to have a snare that has this size That is appropriate for the polyps.

00:09:20: so forth the small polyps.

00:09:21: we are talking ten millimeters?

00:09:23: That's a good snare.

00:09:24: And why?

00:09:25: because with cool snaring you are gonna put the snare deletion just in the middle of the snare and you're going to push down the snare with your big wheel, To make sure that you have a parallel plane.

00:09:37: And then it will do a guillotine effect.

00:09:39: You'll cut through With this guillotine effects.

00:09:41: So you need to make sure That you have surrounding normal mucosa around the poly to Make sure that we do complete resection.

00:09:48: so

00:09:48: you want leave a rim of Normal mucosas Around that polyp when you are resected right?

00:09:54: Yeah

00:09:54: It's an image from a friday that you have in the middle, the yeast and white thing in surrounding.

00:10:01: That is perfect!

00:10:04: Tell us what type of snare do usually use for cold snaring?

00:10:09: Aside from the size that you're

00:10:10: talking about.

00:10:11: Yeah, so it has been said if you have a thin wire It's better to guide your tin.

00:10:16: but To be true this is...it makes it easier But also can do with a braided and normal sneer.

00:10:23: I don't think That really make big difference.

00:10:26: in many of cases You need that the snare is stiff.

00:10:29: This is true that you need a stiff sneer.

00:10:31: What about its shape?

00:10:32: Any...?

00:10:34: If it is oval or round that will facilitate to have the lesion in the middle.

00:10:39: but also, other ones are okay.

00:10:41: I think at end you need get used with one and then work on them.

00:10:47: So i do same thing...i use a small nine millimeter ten milliliter size round stiff wire thin wire.

00:10:54: It's like cheese wire.

00:10:57: Do you people talk about the bubble sign, so you've removed or resected this.

00:11:02: Do then use your water jet to basically inject water into the base there?

00:11:07: Totally I think that's how it works and we have to be using it all of our time.

00:11:14: It helps us clean first and then you'll get an optical diagnosis quick-optical diagnosis.

00:11:20: Then remove polyps again with a waterjet.

00:11:24: You will see if you see the submucosa takes the liquid.

00:11:30: You are in a good plane and then also you will see like, the borders of the defect.

00:11:35: we'll go...you will see them sharply and be sure that you have removed the lesion.

00:11:40: And sometimes it's bleeding.

00:11:43: you have to know that intraprocedural bleeding is very normal with this technique.

00:11:47: You don't have take care about it, just need move forward and forget about it.

00:11:55: of course.

00:11:55: then after go back see if its still bleeding but never happens.

00:12:00: It's always stops.

00:12:01: Very

00:12:01: rare even in patients who are taking anticoagulants.

00:12:05: Its very rare

00:12:07: Even small pedunculated lesions also

00:12:10: Correct.

00:12:11: Do you photograph the image that followed before and after, and put it into a patient's report?

00:12:17: Yes!

00:12:18: I think this is important.

00:12:19: but here we need some help from industry And i think its going to come in next year To better document these polyps and know which one corresponds to which one?

00:12:29: Interesting.

00:12:29: To annotate the image

00:12:31: Yeah, okay I mean i do that at this point because of more medical legal.

00:12:36: That im saying here look Here's the polyp and now heres what was there after i resected that polyp?

00:12:41: Alright.

00:12:42: so lets do same thing now step by step hot snare

00:12:45: Hot snare.

00:12:46: So when are we going?

00:12:48: use hot snare?

00:12:49: We're gonna use hot snares for those lesions that are pedunculated And larger than ten For those lesions that are seasile and more than fifteen probably, or more then twelve.

00:13:00: And also whenever you have a doubt the lesion can be something which is not totally normal.

00:13:07: it's better to then you use saline or whatever injectate to elevate the lesion and do hot snare.

00:13:13: For a hot snare, you need a brightened snare because you'll need diathermy effect through this snare And than it will probably be used in larger snares but can also have ten millimeters of snare if polyps are not so big.

00:13:26: You could also do on-the-water EMR for that kind of lesions as well for fifteen millimeter lesion.

00:13:32: In that case what would change is... Because of the diatherm effects do a tenting, you will do the other way around.

00:13:40: You'll just desulfate it and take air out of the colon.

00:13:45: then you can do tenting to make sure that you separate...

00:13:48: To pull away from the wall?

00:13:50: Right

00:13:50: because we don't want to transmit thermal energy.

00:13:53: Exactly!

00:13:55: And what type of diathermy unit are using or settings today?

00:14:02: So, it is true that all these endocats or any computer-assisted endothermia are more safe probably and better to be used.

00:14:11: And so this one we usually use the Endocat in our case with Bio III but there's other ones.

00:14:17: We also use yellow pedal for that.

00:14:20: Yes You're basically... It's a blended cut right?

00:14:24: Exactly!

00:14:25: And you're coagulating because machine can actually sense resistance.

00:14:31: Okay, and that's what we should be using.

00:14:33: And you use the yellow pedal exactly okay.

00:14:36: so What about those polyps though?

00:14:39: That have these big thick stalks.

00:14:41: are you pre-injecting with some epinephrine?

00:14:44: Are you prophylactically clipping them and then taking off the pile of?

00:14:48: what do You doing in those situations?

00:14:50: that's curious.

00:14:51: it's an interesting thing because quite common situation and there is not so much evidence, eh?

00:14:56: And then some controversial evidence.

00:14:58: So we inject...and I think that this is clear.

00:15:00: doing a prophylactic maneuver is convenient for these polyps who have a stalk larger than one centimeter.

00:15:07: But you inject with like what dilute epinephrine?

00:15:10: We use epinephrine diluted with saline Into the stock.

00:15:14: Okay

00:15:15: I have to say that they do a little bit of an EMR in those cases very often.

00:15:19: Okay,

00:15:20: so i do it into the stock but also on the basis as a stock.

00:15:24: okay and um what i usually do is that depending on the stock But very often i try to go really to the bases of the pedunculum.

00:15:32: So it's a little like if i was doing an EMR because i feel That this is safer In case there is invasive cancer.

00:15:38: Because most of t-one cancers fifty percent Of the T one cancer are located in pedunculated polyps And here is where we have more often UPS cancers that are not able to predict it beforehand.

00:15:50: So, when there's a pedunculated lesion larger than twenty millimeters especially the probability of having cancer probably one of the most important.

00:16:00: So you need to remember that and do an emblock resection of this lesion, trying to be as far away from head of polyp.

00:16:08: Because

00:16:09: you want pathologist evaluate with a Haggit score?

00:16:12: Exactly!

00:16:13: Okay does your nurse or put pin into the stock of the polyp because that can retract once you put it in to a bottle.

00:16:21: Exactly,

00:16:22: so this is clearly how it has been demonstrated and works but we don't do it.

00:16:27: Okay well your honest

00:16:29: We know

00:16:30: what either.

00:16:31: I think nobody does it But the pathologist really ask us to do It.

00:16:35: Well one my mentors Fred Weinstein who Now, deceased was a gastroenterologist but also pathologist.

00:16:42: And he did pin all the pedicles because of that reason and wanted to make sure there is no invasive cancer through the pedicle.

00:16:50: Yeah, we did a consensus with the pathologists and also stated to do that.

00:16:54: The reality is what... We finally don't do it but most of them are able to assess because they're really good.

00:17:01: What for them?

00:17:02: confronting?

00:17:03: sometimes we label lesions as pedunculated And there's pseudo-pedunculating.

00:17:09: Those are scylesians who have done a pseudo-pedunculum.

00:17:12: This is very important when you learn to differentiate totally sure that this is a pedunculate lesion, it's better to describe as a pseudo-pedunculated because then there will be a scissile lesion and completely changes the approach once you have to rate the risk factors in case of T-one cancer.

00:17:33: What about do you prophylaxically clip stocks sometimes?

00:17:38: I usually do epinephrine and cut and then I do clipping not the other way around.

00:17:44: But it is true that we also, I do a lot of patients who have adrenal polyposis and amatoma dose polyps.

00:17:51: So in those cases sometimes i do the other way around because they really long pedunculums.

00:17:56: so I know being away from the clip.

00:18:02: Yeah, if you're going to prophylactically clip just always make sure You Make your cut above The Clip not below it

00:18:10: and I'm Not close either Exactly of the diathermy

00:18:14: exactly.

00:18:14: you could transmit that thermal energy.

00:18:16: i sort Of do It on a case-by-case Basis.

00:18:19: The problem is sometimes when you don't put that on, because sometime it's hard to put the clip-on.

00:18:24: It may be in a funny position and not always straightforward at least from my experience but some times it will bleed And then your sort of oh man why didn't I put this on there before?

00:18:34: But somtimes i'll clip after or somtime ive clipped before.

00:18:37: Usually even if it bleeds you have time for it afterwards.

00:18:40: You do!

00:18:42: If it is a pedunculated lesion ,you've got good positions.

00:18:47: You need it to consider.

00:18:48: One important thing about clipping a pedunculated lesion is that you need make sure the clip will compress the artery, so don't put in top of the pedunculum because this is not... You want go into base and compress

00:19:04: Absolutely!

00:19:05: And sometimes may needs have couple there.

00:19:08: That's why I do like an EMR Because then close the defect.

00:19:12: What potential complications are with cold or hot snare?

00:19:17: I

00:19:17: think that for the small polyps, we are talking about a very safe technique anyway.

00:19:22: But this thing is something you do very often.

00:19:26: so even if it's in percentages save... Then important because even if it happens only one every thousand, If you do thousands of them then its going to happen.

00:19:37: So that's why we need to have that in mind and be sure Of the general context of the patient.

00:19:44: so The major risk is bleeding And what are feared off Is not the intraprocedural bleeding That will able treat but post-procedural Bleeding.

00:19:53: This I think something has to have In mine.

00:19:56: thats why colisnering might be safer than any other.

00:20:00: So with hot snaring, what do we need to worry about?

00:20:03: Aside from... We've touched a little bit of thermal injury and maybe post-polypectomy syndrome in those situations.

00:20:09: What else?

00:20:10: You always can do perforations.

00:20:12: that's our major fear and you can do that also with cold snaring.

00:20:15: You have to know it.

00:20:16: so yeah, It's not something that happens very often but it can happen...it is not impossible especially for fragile patients probably.

00:20:24: So if you do a good inspection of the defect as we were saying before With the bubble sign then there are some things which aren't okay or you always can clip it And solve them.

00:20:34: The thing about doing most what you could during procedure To avoid delay complications those are ones We don´t want.

00:20:42: Can I ask you a couple things on patient factors?

00:20:45: In other words, before you even start the colonoscopy.

00:20:48: You're looking at that patients age potential comorbidities medications out there and how does that potentially influence your Potential decisions with resection when you get into the colon?

00:20:58: i think we have to Get more And More used To take That Into Accounts and to Have A general Framing of what We are Doing.

00:21:05: and I Think that one Question is if it Is convenient to be Treating eighty-five years old patients with small polyps.

00:21:12: Because even if the risk is low, I don't think that their benefit is any.

00:21:16: but this something we need to work on it as an endoscopy community and i think we have to run trials...

00:21:23: And we know that patients are living longer.

00:21:29: We do not always want them to stop.

00:21:32: And then we are talking about prevention.

00:21:33: We're not treating anything, preventing something.

00:21:36: so you need to have that in mind.

00:21:37: but once this is clear the second thing very important is anticoagulant and anti-platelet treatment.

00:21:44: This a very important factor here.

00:21:46: somehow it's paradoxical.

00:21:48: You would think hot snares safer than cold snares for those patients and its other way around.

00:21:53: So if one patient is anti-coagulated or an anti platelet treatment I will favor even more cold snail

00:22:00: Absolutely.

00:22:01: And this is something, maybe it's not the first thing you would... It's so intuitive but these are clear.

00:22:08: Absolutely

00:22:09: I agree because after we hot snare there's an ulcer that develops and gets larger which has a greater tendency to bleed especially on patients who some type of an anti-thrombotic agent.

00:22:21: Exactly, with cold snare you have a nasty wound in the moment that you do it but its just superficial.

00:22:27: It will heal.

00:22:28: With hot snaring You'll have nice wounds and looks very nice But there is diathermy effect which transforms into an ulcer And here's where this problem appears.

00:22:39: So as we're starting to get at end I want ask about training.

00:22:43: What are your recommendations on?

00:22:45: how does trainee or a young endoscopist become competent in snare resection of polyps.

00:22:52: Yes, now there is very nice tool.

00:22:54: I just tried it out at this congress and one good thing about Congress as well eh?

00:23:00: It's to train on therapeutic and there is a very nice model for training on polypectomy.

00:23:06: But, There are several models to train with Polypectomy And you can even do your own one because it just... With the box and an endoscope its easy Because what we need to do is tip control and learn To put your polyp at six o'clock position and then Just train in a gym.

00:23:22: lets say You know that in UK they have developed this DOP thing.

00:23:26: That exactly I was going ask you Which i think

00:23:28: is really interesting.

00:23:29: We're trying to apply it as well at home now?

00:23:32: Yeah, for our podcast listeners that's really important.

00:23:35: That there is DOPS which the UK has developed that objectively...is a tool to objectively evaluate the skills not just of performance of colonoscopy but of polypectomy as well.

00:23:49: And ESG is also going to be working on these types of objective measures, too certify competency.

00:23:56: I think it's extremely important as we go forward because These are the people who will taking care us one day right?

00:24:03: Yes

00:24:04: First of all, this has been a great conversation.

00:24:06: I have my yellow glasses.

00:24:08: you Have your orange glasses which i really like and they're very similar.

00:24:11: so This is very cool.

00:24:13: But tell us when You're not doing endoscopy what do you Do?

00:24:16: What does professor police say do in her free time or activities?

00:24:20: Is there life after endoscopic?

00:24:22: yes There better be.

00:24:24: So, yeah.

00:24:26: I do...I like very much family and friends times.

00:24:29: so i do a lot of that kind of social thing because I like having people at home for lunch And then I really like nature and work in the woods on the seaside.

00:24:41: I am very much of an nature person.

00:24:42: Yeah

00:24:42: Barcelona you have to see.

00:24:44: We have the sea we have mountains!

00:24:46: And I love it.

00:24:47: It's for these lunches?

00:24:49: Are they big cooked?

00:24:50: Do you cook them?

00:24:52: No, it's even better.

00:24:53: I have an excellent husband.

00:24:56: He is the cook in a family?

00:24:58: Really!

00:24:59: For these kind of social things...I am the cook for them every day.

00:25:02: so i'm just there enjoying people.. I

00:25:05: hope my wife isn't listening to this podcast because she'll get the wrong idea and start cooking for their families holidays or dinners.

00:25:12: My wife has an outstanding cook So I would not stand up.

00:25:17: Yes.

00:25:17: Listen, I want to thank you again for being on this very special podcast that we recorded live from ESG days twenty-twenty six in Milan.

00:25:26: Thank You Again Maria Polisei For Being My Guest Today.

00:25:29: It's Been Great!

00:25:32: For example, to browse our scientific publications, interact with the online learning portal ESG Academy or learn about becoming a member of ESGE.

00:25:53: Visit our website www.esge.com And your feedback is always valuable!

00:26:00: So send us your thoughts via podcast at esg.com.

00:26:05: Thanks for listening and join next time.