Endoscopic resection of large pedunculated polyps with clipping, ligation, and a scissor-style knife. Authors Kotaro Oka, Shannon J. Morales, Ashley A. Varadaya, Sophia Yuen, Gregory Haber. Case 1. A 58-year-old man without significant past medical history was found on outside colonoscopy to have a large, multilobulated mass in the sigmoid colon in the nest of diverticuli. It was biopsied and tattooed. Pathology revealed tubular adenoma. The stalk was short but wide, leaving little room for resection. We decided to clip the stalk. We were concerned that once we clipped the stalk, there would be little room for resection. We were concerned that if we used a snare, we would be unable to ensure R0 resection. We decided to use the scissor-style knife, which would give us greater control over the plane of resection while allowing us to use both cutting and coagulation currents. Here, the knife is used on the cut setting. Again, the knife is being used on the cut setting. Blood oozes from the base. Here, the knife is used on the coagulation setting to control bleeding. Note the bubbles that appear as the tissue is coagulated. With this final cut, the polyp is detached. Case 2. A 64 year old woman with a BRCA2 mutation, status post prophylactic total abdominal hysterectomy and bilateral salpingo-oophorectomy, was found on an outside colonoscopy to have a 30 millimeter polyp at the hepatic flexure. Pathology revealed tubular adenoma with inflammation and granulation tissue. While the polyp was rather large, the stalk was wide and short. We decided to apply the ligature to the base of the stalk and to then use the scissor style knife to resect the polyp. While a snare could be used here, it makes it more difficult to control the plane of dissection and increases the chance of accidentally cutting the ligature. Here on near-focus and near-band imaging, the interface between the edematous stalk and the adenomatous tissue can be seen above the ligature. One clip is placed below the ligature for extra insurance. The scissor style knife is being used here to cut the polyp just above the ligature clip. The knife is being used here on the cut setting. Note that the ligature and the clip are in place on the polyp base, providing effective hemostasis. Case 3, ligation and scissor-style knife. A 49-year-old man with reflux and heartburn on omeprazole 20 milligrams daily was found on EGD to have a pedunculated submucosal lesion in the duodenal bulb. It was thought to possibly represent Brunner's gland adenoma. On endoscopic ultrasound, the lesion appeared to come off of layer 3 and appeared isochoic. The risk of perforation and bleeding is higher in the duodenum, so control of the dissection plane is more important. Pedunculated polyps were resected with clips, ligatures, and a scissor-style knife. Hemostatic clips and ligatures were placed at the base of the stalk to prevent bleeding prior to resection. Then, the small scissor-style knife was used to transect the polyp below the area of visible adenomatous change on the polyp. Clinical Implications Polyps with wide and short stalks may be difficult to resect with a snare because the endoscopist cannot see the precise location of the snare on the far side of the polyp. This may result in bleeding, incomplete resection, and severing of the ligature. Use of a scissor-style knife allows for resection under direct vision, giving the endoscopist greater control. A ligature has a lower profile than a clip, leaving more room for resection. In our examples, it also reduced bleeding. Placement of clips and or ligature followed by resection with a scissor-style knife can be used to resect pedunculated polyps. It may have advantages over resection with a snare. Use of a ligature to secure the stalk prior to resection with a scissor-style knife is a novel technique with established devices and has not been previously reported.

Endoscopic Resection

Large Pedunculated Polyps

Clipping

Ligation

Scissor-Style Knife