Successful ESD of a gastric hamartomatous inverted polyp intussuscepted into a pylorus ring using a clip with a line attachment prior to incision

Although various endoscopic and surgical resections for a gastric hamartomatous inverted polyp (GHIP) have recently been reported [1] [2] [3], indications for the choice of resection method have not been established because it is a rare form of gastric polyp. The usefulness of a clip with a line attachment prior to incision for endoscopic submucosal dissection (ESD) has recently been reported [4] [5]. Here we report successful endoscopic resection of a huge GHIP easily intussuscepted into a pylorus ring using a clip with a line attachment prior to incision.

A 24-year-old woman presented for black stool (hemoglobin level of 9.9 g/dL). Esophagogastroduodenoscopy showed that a huge submucosal tumor (SMT) arising from the greater curvature of the pylorus ring and duodenal bulb was intussuscepted into a pylorus ring, and the lesion was retracted into the stomach ([Fig. 1] a). Endoscopic ultrasonography showed a heterogeneous lesion in the third layer of the gastric wall with variable cystic components ([Fig. 1] b). For a definitive diagnosis and treatment of this SMT, ESD was performed because distal gastrectomy is invasive.

Fig. 1 Showing esophagogastroduodenoscopy and endoscopic ultrasonography. a A huge submucosal tumor arising from the greater curvature of the pylorus ring and duodenal bulb was intussuscepted into a pylorus ring, and the lesion was retracted into the stomach. b A heterogeneous lesion in the third layer of the gastric wall with variable cystic components.

The lesion was intussuscepted into a pylorus ring before starting ESD. First, a clip with a line was attached to the top of it, and powerful traction was applied to it prior to incision for ESD. Next, it was pulled back into the stomach using a clip with a line and grasping forceps ([Fig. 2] a). Because it was kept in the stomach, a mucosal incision was easily made in the anal side of it in retroflex view of the duodenal bulb ([Fig. 2] b). We easily made a mucosal incision and dissection was performed with the lesion kept in the stomach using a clip with a line in a forward view. Finally, it was removed. Histological examination revealed GHIP with negative resection margins ([Fig. 2] c, [Video 1]). The patient’s symptoms disappeared and her anemia improved after ESD. After about 3 months, her ulcer was completely cured and there was no stenosis at the pyloric ring ([Fig. 3] a).

Fig. 2 Successful endoscopic resection of a huge GHIP. a It was pulled back into the stomach using a clip with a line and grasping forceps. b Because it was kept in the stomach, a mucosal incision was easily made in the anal side of it in retroflex view of the duodenal bulb. c Histological examination revealed GHIP with negative resection margins.

Successful endoscopic resection of a huge gastric hamartomatous inverted polyp easily intussuscepted into a pylorus ring using a clip with a line attachment prior to incision.
Successful ESD of a gastric hamartomatous inverted polyp intussuscepted into a pylorus ring using a clip with a line attachment prior to incision. The lesion was intussuscepted into a pylorus ring before starting ESD. First, a clip with a line was attached to the top of it, and powerful traction was applied to it prior to incision for ESD. Next, it was pulled back into the stomach using a clip with a line and grasping forceps. Because it was kept in the stomach, a mucosal incision was easily made in the anal side of it in retroflex view of the duodenal bulb. We easily made a mucosal incision and dissection was performed with the lesion kept in the stomach using a clip with a line in a forward view. Finally, it was removed. The patient’s symptoms disappeared and her anemia improved after ESD. Histological examination revealed GHIP with negative resection margins.Video 1

Fig. 3 Follow-up endoscopy. After about 3 months, the ulcer was completely cured and there was no stenosis at the pyloric ring.

Publication History

Received: 15 October 2023

Accepted after revision: 10 November 2023

Article published online:
19 January 2024

• References

• 1 Ohtsu T, Takahashi Y, Tokuhara M. et al. Gastric hamartomatous inverted polyp: Report of three cases with a review of the endoscopic and clinicopathological features. DEN Open 2023; 3: e198
• 2 Han YP, Min CC, Li YB. et al. Diagnosis and treatment of gastric hamartomatous inverted polyp (GHIP) by endoscopic submucosal dissection: A case report. Case Reports Medicine (Baltimore) 2023; 102: e33443 DOI: 10.1097/MD.0000000000033443. (PMID: 37000057)
• 3 Hayase S, Sakuma M, Chida S. et al. Diagnosis and treatment of gastric hamartomatous inverted polyp (GHIP) using a modified combination of laparoscopic and endoscopic approaches to neoplasia with a non-exposure technique (modified CLEAN-NET): a case report. Surg Case Rep 2020; 6: 200
• 4 Mitsuyoshi Y, Ide D, Ohya TR. et al. Training program using a traction device improves trainees' learning curve of colorectal endoscopic submucosal dissection. Surg Endosc 2022; 36: 4462-4469 DOI: 10.1007/s00464-021-08799-y. (PMID: 34704150)
• 5 Miyamoto S, Ohya TR, Higashino M. et al. Clip with thread attachment prior to incision – new strategy for traction-assisted esophageal endoscopic submucosal dissection. Endoscopy 2020; 52: E328-E329