Today, tips for resection of pedunculated lesions on the ASGE SuTab tip of the week. When we're snaring pedunculated polyps to maximize our oncologic outcome, we want to end up low on the stalk and we need an on-block resection. Getting low on the stalk that is, in case there is cancer in the head that's invading the stalk, we have the greatest chance of having a clear margin. So generally we want to get the snare over the head, it's often helpful to go up proximal to the polyp and then come back and get the snare over the head, get it under the head, and then finally pull the scope back so that we get the far side of the snare, we actually see it hit the stalk on the proximal side. And then to close the snare, we will both close the snare and push the sheath forward to meet the stalk on the anal side, on the scope side of the polyp. And that way we can actually see this closure occurring and make sure that it is low on the stalk and we've ended up with an on-block resection and an optimized oncologic outcome if cancer is present in the polyp. So here's a pedunculated lesion in the sigmoid and the referring doctor has put a tattoo on the lesion next to it and it's a good opportunity to start to demonstrate some of these principles. So first of all, we've got a snare of appropriate size, we're over the lesion and you can see we're pulling back now with the snare mechanism to get the tip of the snare against the stalk on the far side and then we close by advancing the sheath and closing the snare simultaneously. And our first outcome that we're after, we have achieved here because we are low on the stalk. We want to get low on the stalk in case there's cancer in the polyp. And again, it's hard to predict on the basis of the endoscopic appearance whether cancer will be present. About a third of the cancers are invasive into the stalk and so we minimize the chance of a positive margin by getting low on the stalk and then clipping the site closed. Here's one that's more like the drawing I was using on the whiteboard to start this video tip where the lesion is lying proximally from where the base of the stalk is and usually we want to drive the scope up proximal to the lesion, open the snare and then pull it back. But what's critical is that we pull the snare until the tip of it hits the stalk and we see it because we don't want it to hit the head. So our principles are we're going to cut it low on the stalk and we want to get it on block which means that we need to see the distal edge of that snare come all the way back against the stalk before transection. This pedunculated polyp is in the sigmoid and it's lying with the head of the lesion coming distally. You can see the tattoo from the referring physician. This actually was a malignant polyp that had been discovered during a screening colonoscopy in a young man in his 50s and this measured 55 millimeters on the head when we got it out 55 millimeters in length and I think it's okay to put the snare over the head of the polyp and then work our way down toward the stalk but when we do this we have a greater risk of the tip of the snare getting caught on the head of the polyp and we have to follow this basic principle that we're going to get this thing out on block if we possibly can. So we're getting down at the base and now we're just shaking that thing until we actually and we've got quite a bit of the snare inside the scope but you can see that the tip of the snare was up against the stalk down low and so we're following our basic principles do a non-block resection and cut the stalk low and we're using forced coag current so very low risk of bleeding and then clip the stalk. So the question becomes how are we going to keep these principles of resection of pedunculated lesions for more difficult lesions where we could be tempted to piecemeal because it's hard to get the snare down around the head and on the stalk where we want it. This is an example of this. The first step we did is to rotate the stalk into the five o'clock position that's pretty much what we always want to do. We're in the sigmoid again this lesion is hanging proximally but it's sort of going over a fold and you can see that the point of the snare the tip of the snare is getting caught on the head so we can try to work it down around that but the easiest way to solve this is by water filling. We use water filling in an earlier tip to float up a lesion that was on the proximal lip of the ileocecal valve and now we're going to use it to float up this pedunculated polyp in the sigmoid and this is a great tool for sigmoid pedunculated polyps because the sigmoid is fantastic for water filling. It's very narrow so it fills really easily with water. We're sucking gas out pumping water in and it's also dependent when you're in the left lateral bicubitus position which we usually are in for colonoscopy so it fills really well and you can see the tip of the snare slipped off the head of the polyp and now we're going to close on the stalk. We're closing low again. We're going to prevent immediate bleeding by using forced coagulation current. We almost never see immediate bleeding in the removal of pedunculated polyps when we use forced coag current and then the all-important delayed bleeding which is a problem because the patient has to come back to the hospital. We're going to prevent that by clipping but clipping after we have resected low on the stalk. That's the principle that we're following. Here we will use water floating again. The lesion is lying between a couple of haustral folds in the sigmoid off to the left. We want to get it stood up where it's easy to snare, get it into that standing up mushroom conformation. We're over the top of the polyp now. You can tell from all the action of the mucus and so on that we're literally pumping water continuously as we're doing this. The water jet is just going non-stop in order to really get the polyp head floating up well. Now we've worked our way around the stalk and we're going to back off, get that point up against the far side of the stalk and then push the sheath forward to meet the stalk. Once again, we're low on the stalk, optimal from an oncologic standpoint if there's cancer in the stalk. One more example of how water floating helps with snaring pedunculated sigmoid lesions that are lying in a suboptimal position. This one lying toward the proximal colon. As soon as we get the colon filled with water, we see that it stands upright in the upright mushroom position becomes easy for snaring. I think in the past when we tended to use position change, that is rotate the patient from left lateral to cubitus to supine to improve the snaring position of a pedunculated sigmoid polyp. Now, for the most part, we can do it just with water filling, which is easier. We're going to use forced coag current, any current that you want to use, but we're using forced coag to limit immediate bleeding. We'll work fine under water as demonstrated here. Again, we are low on the stalk and then we prevent delayed bleeding by application of clips. Finally, remember that changing the patient's position is an option for facilitating snaring of large pedunculated lesions. This lesion in the ascending colon was tipped toward the cecum and we have injected it with epi. You can see a couple of other pedunculated polyps that are lying there after they've been resected. We moved the patient from left lateral to cubitus to supine and the lesion flipped back toward the anal side, hanging toward the anal side where we could do a nice on block resection of the lesion. So remember this as an option to facilitate snaring of pedunculated lesions, position change of the patient. Summarize techniques that optimize all the outcomes with large pedunculated polyps, both the bleeding risk and the chance of a clear margin if cancer is present. You want to see the far side of that snare, the tip of that snare close on the stalk. If you're having difficulty achieving a snare position that will give you an on block resection, then fill the colon with water or as a final resort, change the patient's position, cut low on the stalk to maximize the chance that if there's invasion in the stalk, you'll have a free margin. Use forced coag current to minimize immediate bleeding and clips in the stalk to minimize delayed bleeding. I think the only situation where this is not the best outcome is if the cost of clips are too much for the resources of the unit. But if you have those resources, I think this is the best approach to optimize all outcomes. Next week, scope rotation and positioning for polyp resection on the ASGE SuTab tip of the week. For more information, visit www.ASGE.com

resecting pedunculated lesions

oncologic outcomes

clear margins

snare technique

forced coag current