Endoscopy 2020; 52(01): E15-E16
DOI: 10.1055/a-0978-4839
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© Georg Thieme Verlag KG Stuttgart · New York

Polypectomy of a giant sessile polyp in the hepatic flexure using scissor-type forceps and a gravity traction method to create a pseudo-peduncle

Felipe Ramos-Zabala
1  Department of Gastroenterology, HM Montepríncipe University Hospital, Boadilla del Monte, Madrid, Spain
2  Department of Clinical Sciences, School of Medicine, University of CEU San Pablo, Boadilla del Monte, Madrid, Spain
,
Alejandra Alzina-Pérez
1  Department of Gastroenterology, HM Montepríncipe University Hospital, Boadilla del Monte, Madrid, Spain
2  Department of Clinical Sciences, School of Medicine, University of CEU San Pablo, Boadilla del Monte, Madrid, Spain
,
Jorge Vásquez-Guerrero
1  Department of Gastroenterology, HM Montepríncipe University Hospital, Boadilla del Monte, Madrid, Spain
2  Department of Clinical Sciences, School of Medicine, University of CEU San Pablo, Boadilla del Monte, Madrid, Spain
,
Marian García-Mayor
1  Department of Gastroenterology, HM Montepríncipe University Hospital, Boadilla del Monte, Madrid, Spain
,
Ana Domínguez-Pino
3  Department of Anesthesiology and Resuscitation, HM Montepríncipe University Hospital, Boadilla del Monte, Madrid, Spain
,
Irene Rodríguez-Pérez
4  Department of Pathological Anatomy, HM Puerta del Sur University Hospital, Móstoles, Madrid, Spain
,
Luis Moreno-Almazán
1  Department of Gastroenterology, HM Montepríncipe University Hospital, Boadilla del Monte, Madrid, Spain
2  Department of Clinical Sciences, School of Medicine, University of CEU San Pablo, Boadilla del Monte, Madrid, Spain
› Author Affiliations
Further Information

Corresponding author

Felipe Ramos-Zabala, MD, PhD
Department of Gastroenterology, HM Montepríncipe University Hospital
Av. de Montepríncipe, 25
28660 Boadilla del Monte, Madrid
Spain   
Fax: +34-91-7089900   

Publication History

Publication Date:
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.

Zoom Image
Fig. 1 a Abdominal computed tomography revealed a tumor (arrow) in the hepatic flexure, without lymphadenopathy or infiltration of the pericolic fat. b Diagnostic colonoscopy revealed a giant protruding polyp, type 0-Is in the Paris classification.

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.


Quality:

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 [1] ([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.

Zoom Image
Fig. 2 Creation of a pseudo-peduncle, taking advantage of gravity (gravity traction method).
Zoom Image
Fig. 3 Use of the distal cap facilitates exposure of the dissection plane between the lesion and the muscular layer.
Zoom Image
Fig. 4 The muscle-retraction sign was seen.
Zoom Image
Fig. 5 a The resected specimen was 48 × 35 mm in size. b Histological examination revealed a tubular adenoma with low grade dysplasia. The resection margins were clean and included muscle fibers of the main muscle layer.

Unfortunately, most cases of endoscopic resection of complex polyps are limited to a piecemeal technique because of the types of polypectomy snare used [2].

However, we now have fast, easy, and safe endoscopic submucosal dissection (ESD) devices [3], that can help in performing en bloc resection.

This case report, similarly to previous ones [4], 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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Competing interests

None


Corresponding author

Felipe Ramos-Zabala, MD, PhD
Department of Gastroenterology, HM Montepríncipe University Hospital
Av. de Montepríncipe, 25
28660 Boadilla del Monte, Madrid
Spain   
Fax: +34-91-7089900   


Zoom Image
Fig. 1 a Abdominal computed tomography revealed a tumor (arrow) in the hepatic flexure, without lymphadenopathy or infiltration of the pericolic fat. b Diagnostic colonoscopy revealed a giant protruding polyp, type 0-Is in the Paris classification.
Zoom Image
Fig. 2 Creation of a pseudo-peduncle, taking advantage of gravity (gravity traction method).
Zoom Image
Fig. 3 Use of the distal cap facilitates exposure of the dissection plane between the lesion and the muscular layer.
Zoom Image
Fig. 4 The muscle-retraction sign was seen.
Zoom Image
Fig. 5 a The resected specimen was 48 × 35 mm in size. b Histological examination revealed a tubular adenoma with low grade dysplasia. The resection margins were clean and included muscle fibers of the main muscle layer.