Key practical points with pedunculated polyps

1. As previously, position the patient so that base of the stalk lies opposite to gravity – this allows blood to pool away from bleed point and improves visibility and also makes snare positioning easier
2. Snare position for resection on stalk is important to achive clear margins and to make life easier to treat and post resection bleed as per picture below
3. For small, thinner, longer stalks – Forced Coagulation rather than Endocut(Blended cut) probably achieves better coagulation to prevent bleed . For significantly thicker, shorter stalks, Forced Coag may cause significant diathermy damage making histo interpretation difficult , so some preinjection into stalk and then Endocut Q may work better in such circumstances.
4. Pressure and duration of snare closure matter significantly to achieve right balance of cutting versus coagulation. Clear instruction to your assistant or doing this bit yourself may be better
5. Temporary hemostasis can be achieved by closing the snare around the remnant stalk and applying pressure. This will give some time for team to get the hemostatic device ready
6. As usual keep the field clear by constant wash with water jet/suction  and don’t allow blood to pool and clot
7. For spurting bleed – either clips or Coagulation grasper or bipolar hemostatic forceps work well

 

​Bleed management during endoscopic therapy – Part 2 – Soft tip Coagulation with Snare

See below short video of mild ooze post Cold snare polypectomy, which did not subside on its own. Its rare to see continued on going bleed post Cold snare. In this case, I noticed continued ooze on extubation atleast 5 mins post cold snare. A clot had already formed and despite this there was ongoing ooze.

​Some tips

1. As previously, Position the patient so that bleeding point lies opposite to gravity – this allows blood to pool away from bleed point and improves visibility
2. Expose the vessel by removing the clot before treating – you can use  snare/roth net or simple suction may help
3. In minor ooze like this, no need to reach out to expensive Coag graspers, clips etc, simple use of snare tip with Soft coagulation mode 60-80 W on ERBE diathermy would suffice to coagulate the vessel by applying pressure against the bleeding point
4. Note that constant irrigation helps to get clear view of the bleeding point for effective hemostasis
5. If this does not work , can reach out to Coag Graspers or hemostat forceps or clips

 

In this 3 part video series I have highlighted some basic tips on bleed management during endoscopic resection.

1. Don’t panic – all bleeding will stop at some point 😊
2. Position the patient so that bleeding point lies opposite to gravity – this allows blood to pool away from bleed point and improves visibility
3. Wash, wash, wash – don’t allow clot to form at the point as this would hamper any attempt to target treat the vessel
4. If available, use soft distal end cap – you can apply mechanical pressure with this and achieve temporary mechanical hemostasis whilst your team get ready with the accessories. This also helps in localisation of exact bleed point more accurately
5. Options to coagulate include
   

• Tip of snare of ESD knife – Soft coagulation mode
• Olympus Coagulation grasper – Soft Coag
• Pentax bipolar forceps – Bipolar setting (In this video I have used pentax bipolar forceps)
• Hot biopsy forceps- cheap and cheerful – Bjorn definitely likes these 😊