A 56-year-old man underwent a screening colonoscopy, in which a
pedunculated polyp, 4 cm × 2.8 cm in size with a
2.5-cm wide flat stalk, was identified in the sigmoid colon ([Fig. 1]). For the safe and complete resection of the
polyp, prophylactic endoclips (Hx-600 – 135; Olympus,
Hachioji-shi, Tokyo, Japan) were applied to both sides of the stalk but
appeared to be ineffective ([Fig. 2]). We then
applied a detachable endoloop (MAJ-254; Olympus, Hachioji-shi, Tokyo, Japan)
over the stalk ([Fig. 3]). Because it was
difficult to capture the stalk by going around the large head of the polyp
using a conventional diathermic snare, we used the Dual Knife (KD-650 Q/U;
Olympus, Hachioji-shi, Tokyo, Japan) with an electrosurgical generator (Endocut
50W; Coagulation 30W; ICC 200; ERBE Co., Tübingen, Germany) to cut the
stalk under direct vision ([Fig. 4];
[Video 1]). After resection, the polyp was gently
dragged into the rectum for spontaneous passage. Histological examination
confirmed the polyp to be a tubulovillous adenoma without malignant change.
Fig. 1 A large pedunculated
polyp with head 4 cm × 2.8 cm in size and 2.5-cm
wide flat stalk seen in the sigmoid colon.
Fig. 2 Despite placement of two
clips on both sides of the wide flat stalk, there was sufficient blood supply
to the polyp and it showed no cyanotic change.
Fig. 3 After applying one
detachable endoloop, the part of the polyp above the level of ligation became
cyanotic and changed shape from flat to columnar, confirming sufficient
tightening.
Fig. 4 Using the Dual Knife for
cutting the stalk of the polyp above the level of ligation under direct
vision.
Video
1 Using the Dual Knife for
cutting the stalk of the polyp above the level of ligation under direct
vision.
In this presentation of a pedunculated polyp with very large head,
conventional diathermic snare polypectomy with en-bloc resection was
impossible. Piecemeal resection of very large pedunculated polyps has been
reported before [1]
[2]; however, we
did not consider this option due to the increased risk of bleeding, and the
risk of an inadequate tissue sample. The Dual Knife, with either a 2-mm
(KD-650L) or 1.5-mm (KD-650Q/U) cutting knife, can be used for the endoscopic
submucosal dissection. The knob-shaped tip of the needle knife makes the needle
less likely to slip during resection of polyps. Cutting the stalk of a polyp
under direct vision is a safe method irrespective of the size of the polyp
head. In conclusion, we consider this technique safe and effective for the
management of such polyps in cases where conventional polypectomy techniques
have failed.
Endoscopy_UCTN_Code_TTT_1AQ_2AD
