EDITORIAL
A knife plus a snare, but how will it fare?
The introduction of EMR revolutionized the gastroenter-
ologist’s ability to resect larger GI lesions, especially
colonic polyps. However, lesions >20 mm in diameter
cannot reliably be removed en bloc by EMR.1 This results
in a piecemeal resection, which renders histopathologic
margins unevaluable and is associated with higher rates
of recurrence, warranting closer endoscopic surveillance
and potentially additional therapy. Endoscopic
submucosal dissection (ESD) is a technique pioneered in
Japan that allows for en bloc resection, generally without
the size limitations of EMR, and can spare the patient
surgical resection if a superficially invasive cancer
(with <1000-mm submucosal invasion) is detected and R0
resection is confirmed. However, ESD is more technically
challenging, carries greater risk, and requires significantly
more time to perform than EMR without proportional
reimbursement, contributing to its slow uptake outside
of Japan, including in the West.
Significant strides have been made in improving the
adoptability of ESD, including observerships/apprentice-
ships with ESD experts in Asian countries, live ESD cases
at meetings and symposiums, English-language textbooks,
more widespread distribution of ESD tools, and invention
of devices intended to enhance the performance and safety
of ESD (eg, scissor-knives, countertraction devices).
Perhaps the most technically challenging and time-
consuming portion of ESD for experts and nonexperts
alike remains submucosal dissection. One technique,
generally referred to as hybrid EMR, has been introduced
in an effort to limit the extent of submucosal dissection
required. Hybrid EMR involves a circumferential incision
around the lesion and, in contrast to ESD, is followed by
only partial submucosal dissection to facilitate snare place-
ment in the submucosal plane and snare resection. An
even simpler technique involving circumferential incision
alone without submucosal dissection before snare resec-
tion is referred to as precut EMR.2 In a recent meta-
analysis of 16 studies comparing the outcomes of hybrid
EMR and conventional ESD, hybrid EMR was associated
with shorter procedure times (mean difference 18.5 mi-
nutes) and fewer adverse events.3 Although hybrid EMR
was associated with relatively low rates of en bloc
resection (82%), there were no significant differences in
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recurrence or need for surgery when compared with
conventional ESD.
Currently, hybrid EMR entails the use of a dedicated
ESD knife to perform the incision and dissection, fol-
lowed by a separate snare, adding to the number and
cost of consumables for the procedure. The tip of a con-
ventional snare has been used instead of a knife in
hybrid EMR but is much bulkier and unwieldy.4
Recently, 2 multifunctional snares have been designed
to facilitate the performance of hybrid EMR (Souten,
Kaneka Medics, Tokyo, Japan; Ksnare, Pentax Medical,
Tokyo, Japan). Both snares feature a straight
noninsulated knife-tip that, when partially opened in
Plans for a multicenter study are noted, and we
hope it will include trainees using precut/
hybrid EMR techniques. Data in experts’ and
nonexperts’ hands outside of Japan will also
eventually be needed for the experience to
be generalizable.
the sheath, can be used for marking, mucosal incision,
and submucosal dissection. When it is opened
completely, an oval snare emerges for capturing and re-
secting the lesion. Note that a multifunctional snare is
not a new concept because a snare with an alternating
injection needle designed to facilitate EMR also exists.5
Given the recent introduction of these multifunctional
snares, the published experience to date remains
limited.6-8 It is therefore with great interest that we read
in this month’s Gastrointestinal Endoscopy the study by
Arimoto et al,6 “Evaluation of colorectal endoscopic
submucosal dissection using a multifunctional snare: a
prospective clinical feasibility study.” This builds on the
authors’ initial experience with the device, in which 10
colorectal lesions (median diameter 30.5  4.9 mm)
were successfully resected (100% en bloc and R0) using
hybrid EMR without requiring conversion to ESD.7 In the
current study, the design was notably reversed with the
intent to use just the knife-tip of the snare to perform con-
ventional ESD, and conversion to hybrid EMR or a dedi-
cated ESD knife being considered a failure. There was no
limit to lesion size, but lesions anticipated to have severe
submucosal fibrosis (large polypoid growth or converging
Volume 93, No. 3 : 2021 GASTROINTESTINAL ENDOSCOPY 679
Editorial
folds, recurrent lesions after prior endoscopic therapy,
signs of deep submucosal invasion) were excluded. In
137 colorectal polyps (mean diameter 27.6  8.6 mm) re-
sected by 11 ESD experts across 2 institutions, a remark-
able 100% of cases were successfully resected en bloc
with R0 margins during a mean procedure time of 26.1
 14.3 minutes by conventional ESD with just the knife-
tip snare being used. There were no episodes of perfora-
tion, with delayed bleeding and post-ESD coagulation syn-
drome occurring in 2.2% and 2.9% of patients, respectively.
The authors’ expertise is evident in their use of the
knife-tip component of the snare for all phases of ESD,
with metrics for bloc resection, adverse events, and proce-
dural efficiency that most ESD performers aspire to
achieve. Moreover, this was without the assistance of any
countertraction techniques. This expertise combined with
the study design, however, resulted in no cases requiring
conversion to hybrid EMR and use of the snare, leaving
this component of the device unevaluable.
The authors’ main conclusion is that use of the multifunc-
tional snare ($81) over dedicated ESD knives ($488-$7099)
could be a significant cost-saving measure for ESD. ESD is
more cost effective than surgery or even transanal excision
when performed selectively for colorectal lesions suspected
to harbor superficial cancer.10 However, the cost of ESD
remains substantial after accounting for consumables (ESD
knives, injection needle, submucosal injectant, hemostatic
forceps, countertraction devices), anesthesia, several-day
postprocedure hospitalization (2-4 days typically; 4 days in
this study), in addition to the often lengthy nature of the pro-
cedure itself. The cost may be escalated by important regional
differences as well. Unlike in Japan, ESD in the United States
is typically performed with an anesthesia provider, with
longer procedure times, unreliable reimbursement (in the
absence of a dedicated billing code), and more expensive
postprocedure hospitalization.11 Thus, efforts like this to
consolidate the procedure and thereby reduce the cost of
ESD are not only welcomed but necessary for ESD to
become more adoptable and economically viable.
From the viewpoint of Western endoscopists, the price
of a multifunctional snare in comparison with conventional
snares also decreases the cost of entry and threshold for
attempting to learn and perform ESD techniques. We antic-
ipate that endoscopists interested in performing ESD may
be more willing to attempt precut/hybrid EMR as opposed
to using a comparably priced conventional snare to resect
the same lesion in a piecemeal fashion. Precut/hybrid EMR
may serve as a standalone technique or a bridge to conven-
tional ESD that is likely safer, faster, and easier in nonex-
perts’ hands, particularly in the absence of the structured
training and mentorship programs found in Japan. Howev-
er, experience with multifunctional snares in nonexperts’
hands is lacking because all procedures in this study and
prior studies using the multifunctional snare were per-
formed by experts.6-8 Plans for a multicenter study are
noted, and we hope it will include trainees using precut/
680 GASTROINTESTINAL ENDOSCOPY Volume 93, No. 3 : 2021
Visrodia & Sethi
hybrid EMR techniques. Data in experts’ and nonexperts’
hands outside of Japan will also eventually be needed for
the experience to be generalizable.
We anticipate that lesions for which a multifunctional
snare would benefit most from precut/hybrid EMR are
similar to those outlined for ESD, including polyps that
are nongranular and >20 mm, those that are concerning
for submucosal invasion, and generally lesions in which
snare capture may be difficult (eg, prior endoscopic therapy,
underlying tattoo, and colitis-associated dysplasia). Howev-
er, nonexperts should begin with lesions in the rectosig-
moid colon and avoid large (>40-mm) lesions in which
extensive submucosal dissection may be necessary to facili-
tate snare capture in the submucosal plane, or else risk sink-
ing of the center portion during snare closure and lead to a
piecemeal resection. A complete circumferential incision
may not be required for the successful performance of pre-
cut EMR because techniques to anchor the snare may also
be facilitated by use of the knife-tip.12 Nonetheless,
attempts to use the snare for these techniques should be
pursued after the achievement of competency in EMR and
an adequate understanding of ESD technique, optical
diagnosis for appropriate case selection, and methods to
address bleeding, muscle injury, and/or perforation.
In conclusion, multifunctional snares are an attractive
addition to the endoscopist’s toolbox. The knife-tip ap-
pears suitable for conventional ESD at a fraction of the
cost of dedicated ESD knives. The price point may also
lower the threshold for those seeking to learn ESD and
facilitate less-complex resection techniques such as pre-
cut/hybrid EMR. As more data become available we hope
to better understand the safety and efficacy profile of the
knife-tip in the hands of experts and nonexperts outside
of Japan.
DISCLOSURE
Dr Sethi is a consultant for Boston Scientfic, Olympus,
Medtronic, and Microtech. The other author disclosed no
financial relationships.
Kavel Visrodia, MD
Division of Gastroenterology
Massachusetts General Hospital
Boston, Massachusetts
Amrita Sethi, MD, MASGE
Division of Digestive and Liver Disease
Columbia University Medical Center-NYPH
New York, New York, USA
Abbreviation: ESD, endoscopic submucosal dissection.
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