Detachable Snare

Endoloop Olympus

Fig. 20.25 Possible clip applications for spurting vascular hemor- b rhage.

a The vessel demonstrates lengthwise erosion. A clip is used to close the vessel on either side of the bleeding point.

Fig. 20.25 Possible clip applications for spurting vascular hemor- b rhage.

a The vessel demonstrates lengthwise erosion. A clip is used to close the vessel on either side of the bleeding point.

Bleeding from the open end of a visible vessel. The vessel is occluded underneath the bleeding point with a clip (illustrations based on images provided courtesy of Olympus).

Polypectomy Bleeding

Fig. 20.26 Bleeding from a rectal ulcer.

a Spurting bleeding. b Bleeding source occluded with application of a single clip (Hemoclip, Olympus).

Fig. 20.26 Bleeding from a rectal ulcer.

a Spurting bleeding. b Bleeding source occluded with application of a single clip (Hemoclip, Olympus).

Sigmoid Colon

Fig. 20.27 Visible vessel.

a Polypectomy site with a protruding visible vessel.

b Prophylactic application of a clip closes the potential bleeding source.

Fig. 20.27 Visible vessel.

a Polypectomy site with a protruding visible vessel.

b Prophylactic application of a clip closes the potential bleeding source.

Picture Sigmoid Colon

Fig. 20.28 Several visible vessels.

a Several visible vessels protruding from a polypectomy site. b Application of three clips definitively seals the bleeding sources.

Fig. 20.28 Several visible vessels.

a Several visible vessels protruding from a polypectomy site. b Application of three clips definitively seals the bleeding sources.

Procedure for hemorrhoid ligation

Under visualization with a proctoscope, suction is applied using a special applicator (Fig. 20.30) to an internal hemorrhoid localized above the dentate line. A rubber band is then placed around the base of the suctioned hemorrhoid pile, ligating it (Figs. 20.29, 20.31). The band falls off after a few days leaving a small ulceration. Complications include pain, rebleeding, or, in rare cases, abscess formation. After about three weeks, the ablation site has healed and the next session can proceed.

Other bleeding sources. Bleeding sources in the colon can also be treated using technology and instrumentation commonly used for treating esophageal varices. The ligation device consists of a transparent cap loaded with the rubber bands and mounted on the endoscope tip, a trip wire allowing the deployment of ligatures, and a deployment mechanism that is connected the accessory attachment of the working channel. For using a commercially available ligation device (Sixshooter, Boston Scientific) with a colonoscope, the trip wire must be lengthened (33). The bleeding source and mucosa are suctioned and the ligating band deployed. After a few days, the necrotic area falls off, leaving a flat ulceration. Use of band ligation has been reported in angiectasias in the upper gastrointestinal tract (34), diverticular bleeding (32), and postpolypectomy bleeding (1, 26, 27). However, it is not clear whether simpler endoscopic alternatives could have been used in these cases. One has to remember that loading the device requires withdrawing from the colon and then advancing the instrument again in the colon, this time under decreased visibility due to the cap. After the necrotic tissue has been sloughed off, the ulcers underneath may bleed.

A detachable nylon snare (Endoloop) is available from Olympus. During endoscopy, the tissue is ensnared and ligated by the En-doloop, which then detaches from the instrument. The chief indication is prophylactic, before the removal of larger polyps (Fig. 20.32), in order to prevent rebleeding. The snare can also be used to ensnare and ligate a bleeding polyp stalk (see also Chapter 18).

Anal sphincter Hemor-rhoid pile

Ligation Hemorrhoids

Rubber band with ligated hemorrhoid pile

Fig. 20.29 Schematic illustration of ligation of internal hemorrhoids.

a Suction is applied to the internal hemorrhoid and a rubber band is placed over the hemorrhoid. b Hemorrhoid ligated with rubber band around its base.

Rubber band with ligated hemorrhoid pile

Fig. 20.29 Schematic illustration of ligation of internal hemorrhoids.

a Suction is applied to the internal hemorrhoid and a rubber band is placed over the hemorrhoid. b Hemorrhoid ligated with rubber band around its base.

Suction Band Ligator

Fig. 20.30 Application device for rubber band ligation of hemorrhoids (Paul Drach). The tip of the applicator contains an inner metal ring inside an outer metal ring. The rubber band is placed on the inner metal ring that is in front of the outer ring. The applicator handle has an attachment for a tube connecting it to a suction pump.

Fig. 20.30 Application device for rubber band ligation of hemorrhoids (Paul Drach). The tip of the applicator contains an inner metal ring inside an outer metal ring. The rubber band is placed on the inner metal ring that is in front of the outer ring. The applicator handle has an attachment for a tube connecting it to a suction pump.

Picture Sigmoid Colon

Fig. 20.31 Ligation of internal hemorrhoids.

a Proctoscopic view of the hemorrhoid pile.

b The application device (Fig. 20.30) is advanced through the proctoscope. Suction is applied to the hemorrhoid pile. The forward motion c

Fig. 20.31 Ligation of internal hemorrhoids.

a Proctoscopic view of the hemorrhoid pile.

b The application device (Fig. 20.30) is advanced through the proctoscope. Suction is applied to the hemorrhoid pile. The forward motion of the outer metal ring loops the rubber band over the suctioned hemorrhoid pile. c View of the ligated hemorrhoid pile.

Endoloop Olympus

Fig. 20.32 Endoloop (Olympus). Detachable snares are usually used prophylactically. The Endoloop is lassoed around the polyp stalk and closed to ligate the stalk. The Endoloop can also be used for postpoly-pectomy ligation of a bleeding stalk remnant (image based on illustration provided courtesy of Olympus).

Fig. 20.32 Endoloop (Olympus). Detachable snares are usually used prophylactically. The Endoloop is lassoed around the polyp stalk and closed to ligate the stalk. The Endoloop can also be used for postpoly-pectomy ligation of a bleeding stalk remnant (image based on illustration provided courtesy of Olympus).

Procedure for Endoloop application

First, the round or elliptical nylon snare is grasped with a small hook and retracted into the delivery system. The delivery system is then advanced in the working channel of a flexible endoscope. At the application site, the snare is advanced out of the shaft and unfolds. The snare is lassoed around the polyp stalk and then closed. It is important that the snare not be closed too tightly as this may cut through the stalk. The snare is then detached from the delivery device.

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