Endoscopic resection of a large pedunculated duodenal polyp using a grasping type scissors forceps

A large pedunculated polyp was incidentally discovered during screening esophagogastroduodenoscopy in a 72-year-old woman. The polyp, located in the second portion of the duodenum, had a long stalk and a large head. Its removal was considered to be technically demanding because the head of the polyp occluded the lumen of the duodenum, making it difficult to maneuver the snare over the polyp. The stalk part of the polyp, however, was fully visible, and we tried endoscopic resection using a newly developed grasping type scissors forceps (GSF) (XDP2618DT; Fujinon) ([Fig. 1] and [2]) [1], after obtaining written informed consent from the patient.

Fig. 1 Distal tip of the grasping type scissors forceps. The outer side of the forceps is insulated so that electrosurgical current energy is concentrated at the blade to avoid burning the surrounding tissue.

Fig. 2 Schematic shows endoscopic resection using a grasping type scissors forceps (GSF). a A long metal clip is opened and applied to the stalk near the duodenum. b A long clip is clamping the stalk. c A GSF is grasping the stalk above the clip. d The lesion is cut by the GSF.

A two channel endoscope was used. First, we applied three long clips (HX-600 – 090L; Olympus) to the base of the stalk close to the duodenal wall for the prevention of polypectomy-associated bleeding. Second, the upper part of the stalk was held with the grasping forceps to avoid losing the polyp in the distal duodenum. Third, the polyp stalk was resected about 5 mm above the clip by GSF using auto cut mode 120W ([Fig. 3]). No hemorrhage, perforation, or other complication occurred. Histological diagnosis was a Peutz-Jeghers type polyp.

Fig. 3 a The GSF is cutting the stalk 5 mm above the clip. b The polyp is removed without bleeding. GF, grasping forceps; GSF, grasping type scissors forceps.

Large pedunculated gastrointestinal tract polyps are often difficult to remove by endoscopic polypectomy with the standard snare technique [2] [3] [4]. Our approach was to perform endoscopic resection with a GSF [1]. The GSF has a thin serrated cutting edge to facilitate grasping the tissue. The outer side of the forceps is insulated so that electrosurgical current energy is concentrated at the blade to avoid burning the surrounding tissue. By using the GSF, it was safe and easy to resect the stalk of the polyp. We believe this technique has the potential to become the method of choice for the removal of pedunculated gastrointestinal tract polyps when other procedures involving snaring of the polyp head are not feasible.

Endoscopy_UCTN_Code_TTT_1AO_2AG

References

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