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Cap-Assisted EMR for Fibrotic, Previously Attempted Polyp

Cap-Assisted EMR for Fibrotic, Previously Attempted Polyp A 64-year-old woman was referred for endoscopic resection of a large, non-pedunculated polyp in the proximal rectum. The lesion had undergone partial resection at an outside center, with pathology revealing adenoma with high-grade dysplasia. Due to significant submucosal fibrosis, most of the lesion was non-lifting after injection, rendering standard snare polypectomy unfeasible. The non-lifting portions were resected using cap-assisted EMR (c-EMR) with a standard distal attachment cap. Key Takeaways from the Procedure: 1. Snare Positioning: With the working channel at 7 o’clock in the endoscopic view, position the snare tip at 1 o’clock. Gradually open the snare, advance the cap toward the lesion, apply suction, and close the snare. 2. Use a small snare (e.g., 10 mm). 3. Use snare-tip coagulation of the EMR margin to reduce recurrence risk. 4. Suction Safety: Avoid entrapping the muscularis propria by using controlled suction and preventing a “red-out” appearance. 5. Olympus offers dedicated caps with grooves that enable pre-looping of the snare for c-EMR. While these specialized caps are not widely available, the technique outlined above performs effectively using standard distal attachment caps. 6. For fibrotic, previously attempted colorectal lesions where standard snare polypectomy fails, there are other options including FTRD device or cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST) (Shahidi et al., Am J Gastroenterol 2021). The c-EMR with regular distal attachment caps provides a good alternative option for such lesions.