AGA Clinical Practice Update on the Use of Electrosurgery in Therapeutic Endoscopy: Expert Review

This American Gastroenterological Association (AGA) Institute Clinical Practice Update aims to review the available evidence and provide expert advice regarding the use of electrosurgery in gastrointestinal endoscopy.

This Clinical Practice Update was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This manuscript is framed around best practice advice points agreed upon by the authors, based on the current available evidence and expert opinion in this field. Because systematic reviews were not performed, these best practice advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Endoscopists should have a thorough understanding of fundamental electrosurgical principles. BEST PRACTICE ADVICE 2: Endoscopists should have knowledge of the specific electrosurgical unit that they are using and the related electrosurgical settings. BEST PRACTICE ADVICE 3: Endoscopists should understand the concept of current density and that multiple factors influence tissue effect besides electrosurgical unit settings, and therefore, changing the electrosurgical unit settings alone may not achieve the optimal desired tissue effect. BEST PRACTICE ADVICE 4: The endoscopist should adopt best safety practices when utilizing electrosurgery, which includes incorporating a pre-procedure timeout to review electrosurgery safety, optimal positioning of the electrosurgical unit in the room for both visibility and operation, and the use of closed-loop communication among team members prior to electrosurgical unit activation and troubleshooting. BEST PRACTICE ADVICE 5: Either a cut- or coagulation-predominant electrosurgical current can be considered for the resection of colorectal polyps without clear differences in the risk of serious adverse events, complete resection rate, or polyp recurrence. BEST PRACTICE ADVICE 6: Hot instead of cold snare polypectomy should be strongly considered for the removal of large pedunculated polyps as these lesions can often contain thick blood vessels prone to bleeding when transected. BEST PRACTICE ADVICE 7: Following piecemeal endoscopic mucosal resection of colorectal polyps, thermal ablation of the resection margins should be considered to reduce the risk of recurrence. BEST PRACTICE ADVICE 8: Endoscopists should recognize that the operational environment (gas vs fluid) affects the tissue effect. BEST PRACTICE ADVICE 9: Endoscopists should be aware that, although the application of soft coagulation current is an effective hemostatic and ablative technique, it can also cause deep tissue injury and the potential for delayed perforation. BEST PRACTICE ADVICE 10: Hot forceps avulsion using a cutting current can be an effective adjunct technique for removing focal areas of gastrointestinal lesions complicated by non-lifting fibrosis. BEST PRACTICE ADVICE 11: The endoscopist should understand the principles of argon plasma coagulation as a non-contact method of delivering electrosurgical energy and how gas flow and power parameters can be adjusted to achieve the desired tissue effect. BEST PRACTICE ADVICE 12: Endoscopists should understand how to optimally deliver electrosurgical energy to achieve the desired sphincterotomy at the time of endoscopic retrograde cholangiopancreatography while minimizing the risk of immediate/delayed bleeding and pancreatitis. BEST PRACTICE ADVICE 13: Endoscopists performing third-space endoscopy should have in-depth understanding of how to optimize the desired tissue effects while minimizing any off-target tissue damage.