A New Technique for Releasing a Stuck Loop

A detachable loop for preventing and treating postpolypectomy bleeding (Olympus HX-20L/Q/U-1, Olympus Corporation, Tokyo, Japan) was developed by Hachisu in 1990 [1]. It consists of an operating part with a Teflon and stainless-steel coil sheath, a hook wire, and the handle with an attached loop of nylon. The loop is electrically nonconductive and is threaded with a silicone-rubber stopper that maintains tightness around the stalk of the polyp. Deploying the detachable loop is a multistep process involving loading onto the ligating system, extrusion of the loop from inside the Teflon sheath, positioning and tightening the loop around the stalk of a large pedunculated polyp, and loop release. A diathermy snare is then used to cut the stalk of the polyp above the tightened loop.

Although the device may provide safer resection of large, pedunculated polyps, several cases in which its use has proved ineffective have been described [2]. In addition, the loop sometimes remains stuck to the ligating device and cannot be detached even after straightening of the device and the endoscope. The recommended procedure in these situations includes cutting both the Teflon and coil sheaths, as well as the operating wire, near the proximal end using pliers or a similar instrument and withdrawing the endoscope. Then, if there is a gap between the coil sheath and the loop stopper, the endoscope should be inserted along the device and the loop should be cut using the loop cutter (Olympus FS-5L/Q/U-1). However, no recommendations are available for cases in which there is no gap between the coil sheath and the loop stopper. We describe here a new technique for loop removal in this situation.

After the ligating device has been cut and the endoscope has been withdrawn, a diathermy snare is introduced through the endoscope’s working channel, outside the patient, and fully opened. The proximal end of the ligating device is then passed through the snare, which is closed slightly, and the endoscope with the semi-closed snare is slid alongside the endoscope, using the ligating device as a guide wire (Figure [1]), until the polyp is reached. The snare is then positioned and tightened around the silicone stopper and pure cutting current is used to sever it (Figure [2]). Care has to be taken to avoid touching the metal coil sheath with the snare during the 1 - 2 min required to cut the silicone stopper and release the loop. We carried out this procedure in one patient, providing an effective and safe resolution of this technical problem.

Figure 1 Sliding the endoscope and snare, using the ligating device as a guide wire.

Figure 2 Positioning the snare around the silicone stopper.

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References

• 1 Hachisu T. A new detachable snare for hemostasis in the removal of large polyps or other elevated lesions.  Surg Endosc. 1991;  5 70-74
• 2 Matsushita M, Hajiro K, Takakuwa H. et al . Ineffective use of a detachable snare for colonoscopic polypectomy of large polyps.  Gastrointest Endosc. 1998;  47 496-499