Endoscopic resection of an esophageal polyp causing unspeakable problems. Fibrovascular polyps of the esophagus are rare, idiopathic benign polyps that usually arise at the level of the cervical esophagus. When small, they are asymptomatic. However, enlargement may be associated with symptoms of dysphagia, odoniphagia, or dyspnea. Patients may also report a characteristic feeling of a regurgitation of a fleshy mass into the mouth. These polyps can be removed surgically or endoscopically. The choice of which is performed is based on the size, mobility, vascularity, and location of the polyp's base. Typically, endoscopy is used for smaller polyps, whereas surgery is used for polyps over five centimeters because of the thick vascularized pedicle. Polyps in between two and five centimeters are managed based on local expertise. A recent paper reporting resection of 61 of these polyps found that transluminal resection was performed in 27 and surgery in 34. Of the 13 endoscopic resections, a single or double channel endoscope was used in all cases, and a variety of endoscopic tools, including loops, snares, and ESD or needle knives were used. Endoscopic methods employed in this case include submucosal injection of dilute epinephrine, partial incision with an electrosurgical knife, and snare excision and retrieval of the polyp. The case is a 55-year-old male who reported a several-year history of dysphagia in 2001. Upper endoscopy showed a pedunculated polyp in the upper esophagus that was removed that same year by a left lateral neck incision. Pathology demonstrated a benign fibrovascular polyp. He did well for 12 years. When he presented with a one-year history of increasing dysphagia, upper endoscopy showed recurrence of the polyp. The patient was referred back to the surgeon who refused to operate. One year later, symptoms increased, including coughing, gagging, and regurgitation of the polyp into his mouth. Repeat upper endoscopy showed the proximal esophageal polyp had recurred, and the patient was referred to our institution for management. Upper endoscopy showed a mobile, pedunculated polyp prolapsing from the hypopharynx into the trachea. Forceps were then used to grab the base of the polyp in the region of the hypopharynx, and this was pushed distally into the esophagus for planned attempted resection. Endoscopy showed a polypoid, mobile polyp. Palpation with a catheter confirmed a lipomatous, fleshy mass with a pillow sign similar to that seen with a lipoma. Extension of the endoscope proximally demonstrated origin in the region of the cervical esophagus or upper esophageal sphincter. Dilute epinephrine was injected into the base of the polyp prior to planned attempted resection. A 20-millimeter braided snare was inserted A 20-millimeter braided snare was then attempted to be placed around the distal side of the polyp. Due to its mobile, soft nature, this was unsuccessful. An insulated tip knife was then used to try to incise the base of the stalk because of the instability of the upper esophageal sphincter and the mobility of the stalk. This was also unsuccessful. Use of a hooked knife provided some cautery burn and incision, but it was felt to be unsafe. To try to switch orientations, a duodenoscope was placed. A snare was then used to place around the distal side of the polyp. Once the snare was placed, the endoscope and snare were moved in a to and fro motion to ensure that both sides of the polyp were entrapped. Once this was assured, the endoscope was moved proximally to the thermal markings from the electro-surgical knives. Once the thermal markings were visualized, the snare was pushed out and entrapped at this site. Using a combination current of cut and coagulation, the base of the stalk was removed. Inspection with a forward-viewing scope of the region of resection demonstrated thermal markings, but no evidence of perforation. Since the polyp was noted to prolapse from the hypopharynx into the trachea, it was felt to be safe to remove this through the mouth. Using a large snare, one portion of the polyp was grasped and withdrawn slowly out of the mouth. The polyp measured seven centimeters in length. Pathology from the resected polyp showed a seven-by-three-by-1.5-centimeter benign esophageal fibrovascular polyp. The patient remains asymptomatic seven years following resection. Clinical implications from this case dictate that the size, site of origin, mobility, and vascularity of large fibrovascular polyps of the esophagus determines the choice of management. Multiple endoscopic tools are available for resection, but as this case illustrates, resection with a standard forward-viewing endoscope using a snare injection and an ESD knife alone are difficult. In conclusion, we present a novel method for endoscopic resection of giant esophageal fibrovascular polyps. The first step is injection, incision, and thermal marking with a gastroscope. The second is snare excision using a duodenoscope.

Fibrovascular polyps

Dysphagia

Endoscopic resection

Case study

Individualized management