Polypectomy of a giant sessile polyp in the hepatic flexure using scissor-type forceps and a gravity traction method to create a pseudo-peduncle
09 August 2019 (online)
A 60-year-old man with abdominal discomfort was referred to our hospital. Abdominal computed tomography (CT) revealed a tumor in the hepatic flexure and colonoscopy showed a giant protruding polyp ([Fig. 1]). The biopsies were interpreted as adenoma with areas of high grade dysplasia.
Therapeutic endoscopy was performed using scissor-type forceps (Sumitomo Bakelite, Japan) and a RetroView colonoscope (Pentax, Japan) with a distal attachment cap (Olympus, Japan) ([Video 1]).
Video 1 Endoscopic resection of a giant protruding polyp in the hepatic flexure, using scissor-type forceps.
First, we took advantage of the polyp's own weight to exert traction in order to form a pseudo-peduncle ([Fig. 2]). We began cutting the mucosal layer to expose the submucosa. Then, countertraction with a soft straight distal cap facilitated exposure of the dissection plane between the lesion and the muscle layer ([Fig. 3]). We coagulated the larger vessels in advance. At one point, some muscle fibers were identified by means of the muscle-retraction sign  ([Fig. 4]). The resection was completed within 70 minutes without adverse events. The endoscopic resection defect was closed with endoscopic clips (Boston Scientific, United States). Pathology examination showed an adenoma 48 × 35 mm in size with low grade dysplasia. Resection margins were clean and included muscle fibers of the main muscle layer ([Fig. 5]). In the 24-month follow-up no residual adenomatous tissue was observed.
Unfortunately, most cases of endoscopic resection of complex polyps are limited to a piecemeal technique because of the types of polypectomy snare used .
However, we now have fast, easy, and safe endoscopic submucosal dissection (ESD) devices , that can help in performing en bloc resection.
This case report, similarly to previous ones , demonstrates that the scissor-style knife can safely speed en bloc resection in a western setting. Further studies are needed to assess the efficacy and safety of this device when used in the resection of protruding polyps by nonexpert ESD endoscopists.
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