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Hybrid resection techniques (endoscopic mucosal resection [EMR] and endoscopic submucosal dissection [ESD]) [1–5] have been described to facilitate complete removal of flat lesions. They may be useful in challenging cases where the snare slips, such as in laterally spreading lesions of the nongranular type (LST-NG), fibrosis due to previous resection attempts, and submucosal fatty tissue, among other factors. However, endoscopists not experienced in ESD may not feel confident performing circumferential incision with a dedicated knife or the tip of a snare, and indeed would be unsafe if they were inexperienced in this technique. Here we report a novel hybrid EMR technique that is especially useful when the snare slips while performing polypectomy. After submucosal injection, a circumferential incision is made using a standard biopsy forceps, with subsequent bites around the target lesion. This incision facilitates entrapment of the polyp by the snare, preventing slippage when the snare is closed. The lesion is finally cut with cold or hot technique. We have applied this technique to three colonic polyps. 1. A 7-mm flat lesion in the ascending colon, where slippage of the snare was probably related to abundant submucosal fatty tissue (▶Fig. 1, ▶Video1). 2. A 15-mm LST-NG flat lesion in the transverse colon (▶Fig. 2). 3. A 15-mm recurrent lesion (IIa Paris classification) in the sigmoid colon, where slippage was related to fibrosis secondary to a previous incomplete ESD. In this case, a semi-circumferential incision was made with the tip of a K-snare (Pentax, Tokyo, Japan), and completed with a biopsy forceps; finally, a piecemeal resection using a cold snare was successfully completed (▶Fig. 3). Histology in all cases showed tubular adenomas with low grade dysplasia. Hybrid-biopsy EMR is a simple method to completely remove flat lesions. The devices required are widely available and inexpensive, and the procedure can be performed safely by inexperienced ESD endoscopists. Improving the design of biopsy forceps to make them rotatable could make this technique even easier to apply.

Hybrid-biopsy endoscopic mucosal resection: an effective and simple technique for flat colorectal lesions