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.
Fig. 1 Schematic representation of the procedure. a Incision of the stalk mucosa. b Isolated vessels are coagulated using hemostatic forceps. c After cutting the vessels, the dissection is completed. d The defect is then closed with hemostatic clips.
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.
Endoscopy_UCTN_Code_TTT_1AQ_2AD
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
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