A Large Polypoid Vascular Ectasia Removed by Using a Polypectomy With a Detachable Snare in an Asymptomatic Patient

Vascular ectasia is a well-known cause of lower gastrointestinal bleeding in the elderly. Endoscopically, it usually appears as a flat or elevated bright red lesion. We report on an extremely rare case of a large, pedunculated, polypoid vascular ectasia in an asymptomatic patient. A large pedunculated polypoid mass in the sigmoid colon was observed on colonoscopy during a regular health check-up, and a polypectomy was performed using a detachable snare. In histology, vessels with massive dilation were found mainly in the submucosa, which was consistent with vascular ectasia.

Salvage Technique for Endoscopic Removal of a Sharp Fish Bone Impacted in the Esophagus Using a Transparent Cap and Detachable Snares / 대한소화기학회지

A sharp, impacted fish bone in the esophagus is an indication for urgent endoscopy. Endoscopic removal of such an object is a challenging task. An endoscopic protector hood is then used to remove the object. However, an endoscopic hood protector is not always available. In a patient with a large hiatal hernia, the protector hood may not return to the original shape when it passes through the gastroesophageal junction and therefore may not properly protect the esophageal mucosa from the sharp foreign body. In our case, it was impossible to deploy the endoscopic hood protector through the gastroesophageal junction despite multiple attempts. We propose an alternative solution for such cases. We safely removed a large sharp-edged flat fish bone that was folded and compressed using a detachable snare after releasing and pushing the fish bone into the stomach using an endoscope equipped with a transparent cap used for dilating the esophageal wall. This method of using an endoscopic cap and detachable snare is a safe, useful alternative for endoscopically removing a large sharp-edged flat foreign body from the upper gastrointestinal tract. This alternative technique has not been reported in the English medical literature.

A Case of Successful Endoscopic Management of Afferent Loop Leakages by Using Hemoclips and a Detachable Snare / 대한소화기내시경학회지

There are many complications following gastrectomy and one of the most frequent complications is anastomosis site leakage. Postoperative leakage is a serious complication in patients after they undergo gastric surgery. It can lead to the progressive deterioration in the patient's condition and quality of life and the mortality rate is nearly 60%. We encountered a case of a 75 year-old man who had the leakage of the jejunal end of the Roux limb after total gastrectomy. We performed treatment of the leakage endoscopic clipping and detachable snaring. Hemoclips were fixed at the margin of both sides of the lesion. A detachable snare was used to bind both hemoclips, so the interval was made narrow. After snare binding, five hemoclips were used for final closure of the small interval. After treatment, the leakage of the afferent loop end was completely stopped. He resumed an oral intake and was discharged without complications.

A Case of Successful Closure using Endoscopic Hemostatic Clips with a Detachable Snare and Fibrin Glue Injection for a Gastro-Cutaneous Fistula following Buried Bumper Syndrome / 대한소화기내시경학회지

The buried bumper syndrome is a well-recognized long-term complication of a percutaneous endoscopic gastrostomy (PEG). Most of the buried bumpers are removed by making an external incision over the PEG site under local anesthesia or during a laparotomy. Recently, endoscopic removal is usually attempted. While the removal of the PEG tube is usually followed by spontaneous closure of the gastrostomy tract, a non-healing gastro-cutaneous fistula is difficult to manage. The fistula is generally treated with bowel rest and total parenteral nutritional support, suppression of gastric acid secretion, and occasionally, surgical exploration and wedge excision of the fistula site are performed. However, in debilitated patients, surgical management is accompanied with high morbidity and mortality. Recently, the use of nonsurgical alternative methods, such as endoscopic therapy using tissue adhesives or hemostatic clips, has emerged with recent advances in endoscopic technology. We report a case of successful closure using endoscopic hemostatic clips with a detachable snare and fibrin glue injection for a gastro-cutaneous fistula following buried bumper syndrome.

Endoscopic Resection of a Large Colonic Lipoma / 대한소화기내시경학회지

Although colonic lipomas constitute the most common nonepithelial neoplasms of the gastrointestinal tract, colonic lipomas are rare benign tumors. Most colonic lipomas are asymptomatic and are incidentally identified at the time of endoscopy or surgery. Lipomas may cause symptoms such as bleeding, obstruction or intussusception when the size of a tumor exceeds 2 cm. Surgical resection is recommended for larger lipomas to relieve symptoms or exclude a malignancy. There are few published reports on the endoscopic removal of colonic lipomas. Endoscopic snare polypectomy has been used to treat clinically symptomatic colonic lipomas. However, removal of lipomas 2 cm or greater in diameter has been associated with a greater risk of perforation. Using a detachable snare or hemoclipping may reduce the risk of complications after a polypectomy. We report a case of a large colonic lipoma that was treated with endoscopic polypectomy using a detachable snare and hemoclipping.

A Case of Endoscopic Unroofing after Detachable Snare Ligation of a Duodenal Duplication Cyst / 대한소화기내시경학회지

A duodenal duplication cyst is rare congenital anomaly, which accounts for 5% of all gastrointestinal duplication cysts. Most of the duodenal duplication cysts are usually found during infancy or early childhood, and present with obstructive symptoms. The most common clinical manifestations are an intestinal obstruction or, less commonly, hemorrhage, perforation, biliary obstruction or pancreatitis. The traditional treatment of a duodenal duplication cyst has been complete surgical resection, but very few cases of endoscopic treatment of a duodenal duplication cyst have been previously reported recently in the literature. Moreover, endoscopic treatment of a duodenal duplication cyst has not been reported in Korea. We report our first experience of a duodenal duplication cyst, including diagnosis and endoscopic management with a detachable snare.

A Case of Polypoid Arteriovenous Malformation Treated by Polypectomy with Detachable Snare / 대한소화기내시경학회지

Arteriovenous malformations are degenerative lesions of the gastrointestinal tract that occur with a frequency that increases with increasing age. Although the bleeding caused by arteriovenous malformations is typically chronic, slow, intermittent and recurrent, 15% of patients with arteriovenous malformations present with massive bleeding. Any part of the gastrointestinal tract can be involved and arteriovenous malformations usually appear on endoscopy as either flat or elevated discrete bright red mucosal lesions. There are a few cases of colonic arteriovenous venous malformations with a polypoid appearance with some of their endoscopic treatments resulting in profuse bleeding from the remnant stalk. We encountered a case of a polypoid arteriovenous malformation in the colon of a 69-year-old patient with active gastrointestinal bleeding. The patient was treated successfully by an endoscopic polypectomy with a detachable snare.

Endoscopic Removal of Bleeding Duodenal Lipoma Using a Detachable Snare / 대한소화기내시경학회지

Duodenal lipomas are relatively uncommon and asymptomatic unless they are large. Tumors greater than 4 cm in diameter can cause obstructive symptoms as a result of intussusception necessitating a surgical resection. However, acute upper gastrointestinal bleeding is an extremely rare complication. Duodenal lipomas are most often submucosal but they can also be subserosal. Their shape can vary, and they can be either sessile or pedunculated. The overlying mucosa is usually normal but it may be ulcerated. Those that cause symptoms require treatment. Endoscopic snare polypectomy has been used to treat clinically symptomatic lipomas. A detachable snare may reduce the risk of complications after a polypectomy, including bleeding and perforation. We report a case of duodenal lipoma accompanied by massive upper GI bleeding that was treated by an endoscopic polypectomy using a detachable snare.

A Case of Endoscopic Polypectomy Using a Hand-Made Detachable Snare Made of Nylon Fishing Line / 대한소화기내시경학회지

Hemorrhage is the most common complication of polypectomy. Though most bleeding stops spontaneously and can be managed with conservative therapies, some may necessitate intensive therapies. The detachable snare was firstly introduced in 1986. It has been reported that the use of detachable snare can effectively prevent both immediate and delayed bleeding. The detachable snare has been reformed, and now a commercial article is used in practice. But, it is expensive and cannot be used in larger polyps measuring over its fixed size of loop. A hand-made detachable snare made of nylon fishing line was introduced to prevent postpolypectomy bleeding in 2003. We have further improved it and experienced a case of successful removal of a large colonic polyp using our hand-made snare. The hand-made detachable snare is inexpensive and seems to be practical in ligating the polyp regardless of its size.

A Case of Gastric Perforation due to Endoscopic Mucosal Resection Managed by Detachable Snare and Hemoclips / 대한소화기내시경학회지

The detachable snare, by Pontecorvo and Pesce in 1986, was designed for the prevention of bleeding after endoscopic mucosal resection (EMR) of a polyp. It has been used widely for the ligation of large gastric or duodenal variceal bleeding, and even for the resection of a colon polyp. But detachable snare has been rarely used in the treatment of gastric perforation after the EMR. Herein, we report a successful case of detachable snare application in the treatment of gastric perforation caused by EMR in a patient with gastric adenoma measuring 1.6x1.6 cm in size, along with the review of relevant literatures.

A Successful Management Using Detachable Snare for Bleeding from Sigmoid Colonic Huge Mass in Liver Cirrhosis / 대한소화기내시경학회지

Treatment modalities for lower gastrointestinal bleeding are thermal methods, injections, and mechanical devices. Every methods have advantages and disadvantages. The width of selection for the patients with risk factors (liver disease, coagulopathy, or ingestion of anticoagulant or NSAID) is narrow. We experienced a patient with severe bleeding from a sigmoid colonic huge mass. He had hepatic encephalopathy and bleeding tendency associated with liver cirrhosis. Endoscopic ligation using detachable snare was performed successfully. Fortunately, the patient was recovered from hepatic encephalopathy and had a good chance for liver transplantation.

Delayed Bleeding in a Colonoscopic Polypectomy: An experience with 5,236 polypectomies

PURPOSE: Delayed hemorrhage rarely happens after a colonoscopic polypectomy, ranging from 0.2 to 1.8% in frequency. Although its occurrence is unpredictable and it may be serious in some cases, scanty data on its causes, characteristics, and effective management exist in Korea. This study was conducted to provide such data, especially data on the characteristics of delayed hemorrhage and its effective management. METHODS: From 1997 to 1999, one endoscopist at Song-Do Colorectal Hospital performed 5236 polypectomies on 2511 patients. Delayed hemorrhage occurred after 9 of those polypectomies, for a bleeding incidence rate of 0.17% (9/5236). The authors reviewed those 9 incidence of delayed hemorrhage, which involved 9 patients and 9 lesions, with emphasis on the characteristics of the bleeding and the treatment. RESULTS: The mean age of the 9 patients was 50 years, and the male-to-female ratio was 8: 1. The sigmoid colon was involved in 4 of those patients (44.4%), and the right-sided colon was involved in another 4 of those patients. Lesions smaller than 11 mm were either sessile or flat-elevated and accounted for 6 of the 9 lesions (66.7%). The remaning lesions, which were larger than 10 mm, were either pedunculated or semipedunculated. Three (3) of the 9 patients (33.3%) experienced bleeding on day 1, the most common bleeding day. Another 5 patients (55.6%) experienced bleeding during the next 4 days (days 2 to 5). The last patient experienced bleeding on day 9, the latest bleeding day. A snare polypectomy had been performed on 7 of the 9 patients (77.8%), and a hot biopsy had been performed on the other 2 (22.2%). All delayed bleeding was treated by using hemoclips; additional epinephrine injection was used in 55.6% of the cases and an additional detachable snare in 22.2%. Rebleeding was noticed the day following the initial treatment of bleeding in one case and was managed by using hemoclips. CONCLUSIONS: The first 5 days after a colonoscopic polypectomy are crucial, and caution is required during the next 5 days. Thorough knowledge about preventing and managing bleeding is essential.

Clinical Usefulness of the Newly Designed Mini-Detachable Snare Ligation on Esophageal Varices / 대한소화기내시경학회지

BACKGROUND/AIMS: At present, various methods of endoscopic esophageal variceal treatment have been developed. But a superlative method has yet not been developed for endoscopic esophageal variceal treatment. For overcoming various disadvantages of endoscopic esophageal variceal treatment. We manufactured and reported the usefulness of a newly designed mini-detachable snare (stainless steel) in the treatment of esophageal varices. METHODS: In this randomized trial, we performed mini-detachable snare ligation (MDL) on 46 patients who had esophageal varices and we compared the results with the group of multiple band ligation (MBL) performed on 57 patients in the aspects of urgent hemostatic rate, rebleeding rate, eradication rate and recurrence rate etc. from March, 1997 to present. RESULTS: 6 of 7 patients (86%) in mini-detachable snare ligation group and 11 of 13 patients (85%) in multiple band ligation group were successfully controlled by urgent hemostasis. Rebleeding following initiation occured in 2 (5.5%) in MDL group and 3 (5.3%) in MBL group. Esophageal varices were eradicated or reduced to grade I in 96% and 98% by 2-7 snares and 3-10 ligation/one session in 3-9 and 3-8 session (mean+ SD: 4.8+/-2.1 and 4.5+/-1.9 session) in the MDL group and MBL group respectively. The recurrence rate was 5 (11%) and 6 (11%) in MDL group and MBL group respectively during 6 to 16 months follow up period. The mean procedure time taken during 5 snares or 5 bands was 4.07+/-3.8 min and 3.23+/-1.2 min in MDL group and MBL group respectively. No serious complications occurred in both groups. CONCLUSIONS: The mini-detachable snare ligation may be considered as a new and relatively safe, and effective therapeutic modality in the treatment for esophageal varices, Also the mini-detachable snare system is much cheaper than other multi-fire ligation devices but further clinical evaluation and more technical improvements in mini-detachable snare ligation will be needed.

Endoscopic Resection of Large Polyps Using a Detachable Snare / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic resection of large polyps, especially pedunculated polyps with heads 1 cm or greater in diameter, is difficult because of the risk of bleeding. We used a detachable snare to reduce this complication and evaluated its safety and effectiveness. METHODS: Patients with polyps with heads 1 cm or greater in diameter were enrolled to endoscopic polypectomy with a detachable snare. Four patients with duodenal polyps and 8 patients with colonic polyps were enrolled. RESULTS: No bleeding occurred during or after polypectomy with a detachable snare. Besides pedunculated polyps, successful polypectomy was performed on flat type polyps (Yamada type I; 1 case, Yamada type II; 1 case). CONCLUSIONS: Endoscopic polypectomy with a detachable snare may be safer and effective than conventional polypectomy and its use can be applied in various types of polyps other than pedunculated one.

A Case of Endoscopic Polypectomy with a Detachable Snare in a Huge Duodenal Brunner's Gland Adenoma / 대한소화기내시경학회지

Duodenal Brunner's gland adenoma is characterized by hyperplasia of the Brunner's gland, which is usually found in a duodenal bulb as a pedunculated polypoid mass. Conservative management is advocated for asymptomatic small lesions, but in larger lesions causing obstructive symptoms or bleeding, either endoscopic or surgical removal of the mass should be performed. But an endoscopic polypectomy for a huge mass lesion, especially one having a broad base, runs the risk of bleeding, so to minimize this complication, detachable snare is used before the polypectomy. We have experienced a case of huge duodenal Brunner's gland adenoma was successfully removed by an endoscopic polypectomy with a detachable snare, in a patient with recurrent upper gastrointestinal bleeding.

Endoscopic Ligation of Large Gastric Varices Using a Detachable Snares and Rubber Bands / 대한소화기내시경학회지

Bleeding from gastric varices greater than 2cm in diameter represents a major limitation for endoscopic hemostasis. The endoscopic injection sclerotherapy (EIS) using conventional sclerosing agents is not satisfactory for the control of acute bleeding from gastric varices which have large diameter, fast blood flow and abundant collateral circulations. Endoscopic ligation using small rubber bands, known to be alternative to EIS, never obliterate large gastric varices greater than 2 cm in diameter. Obliteration therapy using Histoacryl (n-buty1-2-cyanoacrylate), known to be more satisfactory, has some drawback such as embolization. We per formed endoscopic ligation using detachable snares and rubber bands in 22 patients who had recently bleeding from gastric varices larger than 2 cm in diameter. For ligation of gastric varices larger than 2 cm in diameter, the detachable snares were used, and then for ligation of adjacent small gastric varices, rubber bands were used. In seven patients active bleedings were noted at initial endoscopy; 6 of them were successfully controlled by endoscopic ligation using detachable snares and rubber bands, but one patient who was uncontrolled by it died from bleeding and multiple organ failure. In remaining 15 patients, there were no active bleeding but red color signs on large gastric varices; all of them were successfully controlled by endoscopic ligation using detachable snares and rubber bands. Early rebleeding, fol lowing initial treatment, occurred in two patients (9.5%). So overall hemostatic rate of endoscopic ligation using the detachable snares and the rubber bands was 86.4% (19/22). Varices were nearly eradicated in 18 (85.7%) of the 21 survivors by ligation of 1-3 detachable snares (mean, l.3 snares) and 4-30 rubber bands (mean, 16,2 bands) in 2-6 sessions (mean, 3.2 sessions). During or after ligation, there were no serious complications, except transient epigastric pain or discomfort in 14.7% and fever in 1.3%. These results suggest that endoscopic ligation therapy with detachable snares and rubber bands is a safe and effective method for treatment of acute bleeding of gastric varices, especially gastric varices larger than 2 cm in diameter, which can not he controlled by conventional scleratherapy or variceal band ligation.