Endoscopic Polypectomy of Large Pedunculated Gastric Polyps Using a New, Safe, and Effective Technique

Dear Sir,

We have recently developed a new technique to treat endoscopically large colorectal polyps, which combines excellent results with absence of complications [1]. Since the management of large gastric polyps is still debated, we tried to also apply our technique to the treatment of large gastric polyps.

Six patients (four men, two women; mean age 65.2, range 38 - 85) were included in our study. On esophagogastroduodenoscopy (Fujinon EG300 videogastroscope; Fujinon, Omiya, Japan) they had eight benign-appearing pedunculated gastric polyps of size 2 cm or larger (range 2 - 3 cm) and located in the fundus (n = 3), in the body (n = 1), and in the antrum (n = 4).

Endoscopic removal was done in two steps at the same endoscopic session. First, we placed a polypectomy snare on the middle of the stalk (disposable anchor tip poly snare; US Endoscopy Group, Mentor, Ohio, USA) as a prophylactic measure to prevent post-polypectomy bleeding (Figure [1]). Then, we took out the gastroscope without removing the snare, after it had been dismantled and blocked with a clip. The snare was then kept in place, passing through the nose like a nasobiliary tube. In the second step, we performed endoscopic polypectomy using a second polypectomy snare. Electrocautery current was supplied using the Söring 600 instrument (Söring Medizintechnik, Quickborn, Germany), which was set on “blend” at 2. The polyps were transected at the stalk 2 mm above the location of the first snare. The first polypectomy snare was kept in place, and the patients were discharged within 3 hours after endoscopic polypectomy. We clinically evaluated body temperature and the appearance of thoracic and/or abdominal pain during the time in hospital; we observed no complications. Finally, the first polypectomy snare sloughed off spontaneously and slipped down the nose within 3 days of endoscopic polypectomy. The patients were invited to bring the snare back to us after its expulsion. Complete ensnarement of the head of the polyp with a single application of the snare was obtained in all cases.

None of the patients experienced any immediate or delayed procedure-related complications (such as fever, thoracic and/or abdominal pain or bleeding). At the same time, all the patients tolerated the snare that was left behind very well, and none of them experienced any discomfort (such as heartburn) or showed a temporary residual shallow ulcer. Likewise, delayed complications, such as bleeding, or recurrence of polyps were not recorded in any patient during a 6-month follow-up (Figure [2]).

Endoscopic polypectomy plays an important role in the management of gastric polyps; this is particularly true in patients with adenomatous gastric polyps which are greater than 2 cm in diameter, since it has been reported that this type of polyps frequently contains foci of in situ or invasive malignancy [2] [3].

Since several complications may affect the endoscopic polypectomy of gastric polyps (such as perforation, hemorrhage and the development of symptomatic post-polypectomy ulcer [4], Hachisu has recently developed a detachable snare which enables endoscopic ligation of the base of an elevated lesion [5]. This apparatus encircles the base of a large polyp or other elevated lesion with a specially manufactured loop, which is then tightened, enabling the removal of large polyps and other elevated lesions without bleeding [5]. Unfortunately, bleeding can develop with this technique also, as a result of transection of a thin stalk (4 mm), slippage of the loop in a semi-pedunculated lesion, or insufficient tightening of the loop [6].

Two approaches may be chosen to overcome these problems. First, the gastric polyps may be managed with the laparoscopic minimally invasive method known as endo-organ gastric surgery [7]. However, this technique seems to be limited by greater costs than endoscopic polypectomy and by the presence of some conditions which preclude safe percutaneous endoscopic gastrostomy (PEG) placement (such as obesity, ascites etc) [7].

Secondly, our recently described technique for treating large pedunculated colorectal polyps may be applied [1]. Although our technique seems to obtain results similar to those of Hachisu, in our experience it solves the problems described above. In fact the use of a standard diathermic snare permits easier optimal tightening (the color of the head of the polyp changes to dark red after ligation), both in semipedunculated lesions and in polyps with a thin stalk, since the presence of a manual mechanism of diathermic snare closure allows the tightness to be graded according to the thickness of the stalk.

It is suggested that this technique might be quite cumbersome because of the need to perform a second gastroscopy after placement of the first diathermic snare. In addition, this technique may be considered more awkward when applied to gastric polyps rather than colorectal polyps, because of the need for the patient to have the snare coming out of the nose for several days. However, these disadvantages are outweighed by the excellent efficacy and safety of our approach. Moreover, two other factors seem to guarantee a better cost-benefit performance. First, the cost of the two standard diathermic snares used in this technique is very much lower than that of Hachisu's snare ($ 50.52 vs. $ 189.47, respectively); and secondly, there is the possibility of using the snare again because it is autoclavable.

In conclusion, this study shows that our technique is a good option in the endoscopic treatment of large pedunculated gastric polyps, since it is extremely safe and can be more cost-effective than both standard polypectomy and the use of Hachisu's detachable snare.

Figure 1 Endoscopic appearance of the first diathermic snare (placed to prevent bleeding), after endoscopic polypectomy and extraction of the ensnared polyp. Note the absence of bleeding

Figure 2 Endoscopic appearance of a transected stalk at 1 week after endoscopic polypectomy. The complete absence of bleeding and the scar after polypectomy (thin arrow) may be seen. In the same picture the stalk of a previous polyp which was endoscopically transected 5 weeks earlier can be seen. Note the absence of bleeding and the complete re-epithelization of the transected stalk (thick arrow)

References

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