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DOI: 10.1055/a-2113-9626
Targeted coagulation of large stalk vessels in giant pedunculated colorectal polyp: is endoscopic submucosal dissection the new way to go?
Resection of giant pedunculated colorectal polyps can be tricky to achieve owing to the significant risk of bleeding. The European Society of Gastrointestinal Endoscopy therefore recommends injection of diluted adrenalin and/or mechanical hemostatic prevention, such as the use of a detachable snare in cases of head diameter > 20 mm and/or stalk > 10 mm [1]. However, when the head of the polyp is > 25 mm, it may be difficult to enclose it, leading to a significant risk of incomplete resection.
Endoscopic submucosal dissection (ESD) is feasible in this indication [2] and furthermore allows targeted preventive hemostasis of large submucosal vessels, as previously shown in colonic angiodysplasia [3].
A 65-year-old man was referred with a large polyp in the left colon. Endoscopic examination revealed a giant pedunculated adenoma with a 40-mm head obstructing the lumen. The 15-mm-long, broad-based stalk occupied one-third of the colonic circumference. Large vessels were visible in transparency in the stalk. Placement of a detachable snare prior to endoscopic mucosal resection was deemed difficult because of the bulky head. ESD enabled targeted and safe hemostasis ([Video 1]) of several large vessels, which were successively identified, isolated, coagulated with hemostatic forceps, and cut during the procedure ([Fig. 1], [Video 1]). The defect was closed using clips. The polyp ensnared in a retrieval net was extracted using a bivalve metal Halle dilator, which is used in proctological surgery and allows for nontraumatic anal dilation to avoid damage to the specimen. Pathology analysis revealed a complete R0 resection of adenoma with high grade dysplasia.
Video 1 Exposure of a large stalk vessel during dissection of a giant pedunculated colorectal polyp.
Quality:
In the context of global expansion of ESD, this technique, when mastered, could be used for the resection of giant pedunculated colonic polyps, as it allows targeted preventive hemostasis of the vessels and overcomes the problem of positioning a detachable snare around a head larger than 25 mm.
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Publication History
Article published online:
27 July 2023
© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
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References
- 1 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297
- 2 Chiba H, Tachikawa J, Arimoto J. et al. Endoscopic submucosal dissection of large pedunculated polyps with wide stalks: a retrospective multicenter study. Endoscopy 2021; 53: 77-80
- 3 Bordet M, Jacques J, Grainville T. et al. Submucosal dissection of a large colonic angiodysplasia in case of failure of conventional treatment. Endoscopy 2023; 55 (Suppl. 01) E35-36