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

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.

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.

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.

Fig. 2 Creation of a pseudo-peduncle, taking advantage of gravity (gravity traction method).

Fig. 3 Use of the distal cap facilitates exposure of the dissection plane between the lesion and the muscular layer.

Fig. 4 The muscle-retraction sign was seen.

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.

Endoscopy_UCTN_Code_TTT_1AQ_2AD

• References

• 1 Toyonaga T, Tanaka S, Man-I M. et al. Clinical significance of the muscle-retracting sign during colorectal endoscopic submucosal dissection. Endosc Int Open 2015; 03: E246-E251
• 2 Angarita FA, Feinberg AE, Feinberg SM. et al. Management of complex polyps of the colon and rectum. Int J Colorectal Dis 2018; 33: 115-129
• 3 Homma K, Otaki Y, Sugawara M. et al. Efficacy of novel Sb Knife Jr examined in a multicenter study on colorectal endoscopic submucosal dissection. Dig Endosc 2012; 24: 117-120
• 4 Ge PS, Thompson CC, Aihara H. Endoscopic submucosal dissection of a large cecal polyp using a scissor-type knife: implications for training in ESD. VideoGIE 2018; 3: 313-315