THE BUBBLE SIGN. A NEW TRACK TO DETECT A PERFORATION AFTER COLD SNARE POLYPECTOMY

Cold snare polypectomy (CSP) is nowadays a highly recommended procedure for treatment of sessile adenomas up to 10 mm in size. Despite this procedure is not widely accepted in larger lesions, prospective and retrospective studies show outstanding results in terms of efficacy and safety, even performing piecemeal resection (wide field CSP). Indeed, in two recent meta-analysis no perforations have been described with this technique.

On the other hand, the scar assessment should be mandatory in order to detect damages in muscular layer. Because of no perforation have been reported with CSP, the evaluation of muscular injuries in this scenario has been unnoticed.

After performing a CSP, we usually irrigate a waterjet over the scar. In case the submucosal layer is intact, the creation of a cushion is observed. However in case of disruption of the submucosal and muscular layer this cushion is missing. We have called this fact “the bubble sign”. Therefore, we present two cases of perforation with CSP in which this bubble sign was missing. Both cases were performed using a Captivator Hexagonal 13 mm snare (Boston Scientific) which is not specifically designed for CSP. These patients were treated by endoclips closure and dissmissed 48 hours later with no adverse events.

In conclusion, despite the perforation with CSP is an unusual event, is important to keep it in mind. Irrigating a waterjet over the scar after the procedure and therefore assessing the "Bubble sign" could help us to detect this adverse event.