Endoscopic polypectomy for giant sigmoid pseudo-pedunculated polyp

Endoscopic therapy for colonic big polyps with dysplasia or early colorectal cancer is an advantageous and relatively non-invasive and less costly treatment than conventional operative methods. This video demonstrates an endoscopic polypectomy for a giant sigmoid pseudo-pedunculated polyp.

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Endoscopic polypectomy for giant sigmoid pseudo-pedunculated polyp

Authors

Gf Donatelli, P Dhumane, S Perretta, B Dallemagne, J Marescaux

Abstract

Endoscopic therapy for colonic big polyps with dysplasia or early colorectal cancer is an advantageous and relatively non-invasive and less costly treatment than conventional operative methods. This video demonstrates an endoscopic polypectomy for a giant sigmoid pseudo-pedunculated polyp.

Type de vidéo

Vidéo chirurgicale

Durée

05'52''

Publication

2011-06

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Jun 2011;11(06).
URL: http://www.websurg.com/doi-vd01en3350.htm

Endoscopic polypectomy for giant sigmoid pseudo-pedunculated polyp

1. Clinical case presentation 00'18''

An 87-year-old man with diabetes mellitus, hypertension and on anticoagulation therapy for cardiac reasons underwent upper and lower endoscopic exploration for anemia. During colonoscopy, a giant 3 x 4cm polyp was found in the distal sigmoid colon. On histological examination, it was confirmed to be a tubulovillous pseudo-pedunculated polyp. This bleeding polyp completely occluded the sigmoid lumen, so it needed to be resected. The patient was referred to our unit for endoscopic resection.

2. Beginning of procedure 00'53''

With the patient under general anesthesia and in supine position, a standard single channel colonoscope was introduced and the sigmoid was insufflated with CO2.

3. Polyp identification 01'03''

About 25cm from the anal verge, a large villous pseudo-pedunculated polyp completely occluding the lumen was visualized. The backward and forward movement of the polyp during the peristaltic movement made it clear that it was a pseudo-pedunculated lesion with a base of at least 3cm.

4. Adrenaline and marker injection 01'24''

A mixture of saline, adrenaline, and Indigo carmine (500 cc NaCl 0.9%, 1 cc adrenaline, 1 cc Indigo carmine) was injected with the double aim to lift up the lesion and reduce the mass of the polyp by vasoconstriction thanks to the adrenaline. The reduction in size of the polyp was mandatory not only to catch it in the snare but mainly to avoid the contact between the polyp’s head and the colonic wall, as this might cause damage to the colonic wall due to the dispersion of current during snaring. 5 cc of liquid were injected, but there still was no satisfactory reduction in size of the polyp in order to allow manipulation with the conventional endoscope. As a result, it was decided to change the scope into a thinner single-channel scope with a calibre of 8.9mm. With the new scope in place, the peduncle was injected under direct vision and also in retroversion. This resulted in a shrunken polyp allowing for easy endoscopic manipulation.

5. Endoloop insertion 02'50''

An Endoloop was then inserted into the scope, opened and passed around the tightened polyp. But the Endoloop could not be locked due to a technical problem. Using endoscopic scissors, the Endoloop was cut and removed by means of a normal biopsy forceps. A new Endoloop was passed around the polyp and locked. This resulted in further decrease in the polyp’s size to less than 3cm.

6. Cutting procedure 04'06''

With a standard snare, the polyp was caught and cut using endocut current. During the cutting procedure, a tent was created to avoid dispersion on the base and to prevent the polyp from touching the colonic wall. The specimen was removed with a Roth net snare and at endoscopy, the polyp’s base was carefully explored. At first glance, there was no bleeding and no perforation. The Endoloop was tight enough and in place on the pseudo-peduncle. The colonic wall looked pale due to the adrenaline.

7. End of procedure 05'01''

For security reasons, 4 standard endoscopic clips were applied on the pseudo-stalk. The procedure lasted for about an hour. In the immediate postoperative period, the patient felt comfortable with a soft abdomen and no pain. He was started on a diet 6 hours later and was discharged on the next day. The histological examination demonstrated a tubulovillous adenoma with high-grade dysplasia and clear resection margins. An endoscopic control will be carried out in one year’s time.