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Severe submucosal tethering can occur at the base of a polyp because of previous failed endoscopic attempts, extensive biopsies, de-novo fibrosis of flat polyps, or tattoo ink being placed inadvertently at the base of the polyp. A scarred submucosa limits the depth and effectiveness of the lifting solution used when resecting a polyp, which makes snare capture of fibrotic polyp segments impossible and risks the resection being incomplete [1, 2]. Japanese authors have suggested endoscopic submucosal dissection (ESD) en bloc resection of fibrotic polyps; however this is technically difficult and carries a higher risk of perforation [3,4]. Supplementary ablative techniques such as the use of either argon plasma coagulation (APC) with prior submucosal injection or hot avulsion using electrocautery biopsy forceps are alternative, simpler, and lower risk strategies [2,5]. The depth of tissue destruction is, however, difficult to accurately judge and viable polyp tissue remains below the cauterized surface when thermal energy alone is used. We report our preliminary experience of a new salvage approach to achieve complete eradication of partially lifting or nonlifting, benign, fibrotic polyps using an ablation and cold avulsion (ACA) technique. After submucosal injection had been performed, a conventional piecemeal snare “lift and cut” endoscopic mucosal resection (EMR) was performed on all polyp tissue where lifting was adequate. Residual scarred tissue was initially ablated using high power APC (ERBE-VIO, 25–40W flow, 1.6–2L/min; Erbe, Tübingen, Germany) and this was followed by “cleaning” of the cauterized polyp tissue using a nonspiked biopsy forceps. Repeat APC application and polyp cleaning were performed until the submucosal scar tissue was visible (●" Fig.1;●" Video 1). The ACA rescue technique was applied successfully (after consent had been obtained from the patients) to 15 consecutive fibrotic polyps after piecemeal EMR polypectomy. An apparent complete polypectomy was achieved in all cases (●" Table1). The avulsed specimens revealed low grade dysplastic tissue, verifying the tissue destruction by APC. Followup of 3–7 months showed residual polyp tissue (2mm and 5mm) in 2 of the 14 patients assessed to date, which was suc-

Augmented endoscopic resection for fibrotic or recurrent colonic polyps using an ablation and cold avulsion technique