You’ve positioned your colonoscope perfectly. The lesion is in view. You advance your snare… and the polyp disappears. Or worse—it’s there, but fibrotic, refusing to lift despite multiple injections.
Standard endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) handle most colonic lesions, but real-world endoscopy presents cases that don’t fit the textbook. From my toolbox today: six alternative techniques that transform “difficult” referrals into manageable outpatient procedures.
The Challenge: When Standard Techniques Fall Short
While snare polypectomy, EMR, and ESD cover the majority of colonic lesions, we frequently encounter scenarios where these methods struggle:
Flat lesions that vanish after cleaning or insufflation
Fibrotic polyps that resist simple snaring
Pedunculated lesions requiring prophylactic hemostasis
Large sessile lesions with central non-lifting areas
Each scenario demands a tailored approach.
Why Mastering Alternatives Matters
Clinical Impact: Knowing how to suction-mark a disappearing flat lesion or perform underwater resection expands your capability to handle complex anatomy safely. It minimizes surgical referrals and converts “impossible” cases into successful endoscopic resections.
Equipment Reality: Lesions vary in size and shape. As I tell my fellows: “One snare does not fit all.” Every endoscopist should master at least two to three different snare types—hexagonal, oval, double-buckle—to adapt to specific polyp geometry.
Clinical Pearl: I prefer snares with excellent expansile memory. Hexagonal or oval snares with double buckles tend to remain nicely expanded after several uses, maintaining their grasping capability throughout the procedure.
Technique #1: Polyp Reshaping (Suction Marking)
The Problem
Flat lesions often become nearly invisible after washing and cleaning. Relocating them wastes time and risks missing the target entirely.
The Solution
Use direct suction to transform a flat lesion into a pseudo-sessile polyp.
What happens: The endoscope tip applies direct suction over flat colonic mucosa. Tissue drawn into the channel creates localized erythema and edema—the “hickey effect.” This creates a visible, raised pseudo-sessile polyp that’s significantly easier to identify and snare.
Step-by-Step Technique
Locate: Find the subtle flat lesion initially
Suction: Draw tissue into the endoscope channel briefly
Release: Tissue remains raised and hyperemic (natural chromoendoscopy)
Resect: The flat lesion is now a “sessile” mound, much easier to capture with your snare
When to Apply
Ideal for: Flat lesions (Paris 0-IIa) that disappear with insufflation or after cleaning
Key advantage: This technique accomplishes two objectives simultaneously—it creates a sessile polyp from a flat lesion AND marks it with submucosal bleeding sites for easy relocation.
Pro Tip: This technique will save you in patients with mobile colons where tiny polyps become challenging to relocate. The submucosal bleeding acts as a natural marker.
Technique #2: The Combo Needle-Snare (2-in-1 Device)
The Innovation
This device integrates an injection needle within the snare catheter, eliminating device exchanges between injection and resection.
How it works: With a large pedunculated polyp in view, the needle extends from the device tip, allowing epinephrine injection directly into the stalk. The needle then retracts, and the snare deploys from the same device—zero device exchanges required. This allows prophylactic injection immediately prior to resection, reducing post-polypectomy bleeding risk.
The device was originally introduced in 2007 with a larger diameter that limited compatibility. Modern versions have reduced diameters and work well with standard scopes.
Key Features
The “Snowman” Snare Shape:
Functions as a three-in-one device: injection needle + two snare sizes
Small shape for initial grasping
Large “figure-of-8” shape for capturing large tissue pieces
Can grasp substantial polyp volumes in a single pass
Clinical Advantages
Speed: No device exchange wastes time or loses position
Precision: Inject exactly where and when needed
Efficiency: Particularly valuable during both EGD and colonoscopy
The full article includes four additional advanced techniques:
Underwater EMR: Why water flotation changes everything for large villous lesions
Knife-Assisted Resection (KAR): Using your snare tip as a cutting instrument—no expensive ESD knife required
Loop-and-Let-Go: The elegant solution for large lipomas with perforation risk
Cap-Assisted Resection: How to suction fibrotic polyps into submission
Complete step-by-step procedures with visual analysis
Pro tips for underwater hemostasis and cushion creation
When NOT to use each technique
Downloadable quick-reference guide
