Endoscopic resection of a large pedunculated colonic polyp using an insulated-tip diathermy knife

Use of dual knife for large pedunculated colorectal polyps

BACKGROUND

Endoscopic resection of large pedunculated colorectal polyps is technically difficult, especially when the polyps are so large that it is either not possible or too difficult to resect them using a conventional polypectomy snare.

AIM

To facilitate the removal of pedunculated colorectal polyps, we developed a new technique using a combination of a dual knife and preventive hemostatic procedures.

METHODS

Nine patients (5 men and 4 women; mean age, 59.8 y; range, 49 to 79 y) with pedunculated polyps >2 cm in diameter were treated with this technique. A dual knife and endoclips or an endoloop were used as needed.

RESULTS

All lesions, except for 1 polyp, were resected endoscopically. The mean time for complete resection was 8.5 minutes (range, 1.5 to 16 min). The procedure time decreased significantly after the fifth case (168 vs. 746 s, P=0.0009). No hemorrhage, perforation, or other complications occurred during follow-up among the endoscopically resected cases.

CONCLUSIONS

Combined use of a dual knife and prophylactic hemostatic procedures is a feasible alternative technique for removing large pedunculated colorectal polyps when conventional snare resection is impossible or difficult.

Endoscopic mucosal resection for early colorectal neoplasia: pathologic basis, procedures, and outcomes

Open access endoscopy and screening programs enable detection and removal of an increased number of colon polyps in the early stages of neoplastic transformation. Unfortunately, polyps larger than 3 cm, involving more than one-third of circumference or two haustral folds, or with a flat/depressed morphology are more challenging to remove with standard polypectomy techniques. Endoscopic mucosal resection potentiates the removal, in a minimally invasive way, of certain colonic lesions that would otherwise require surgical or ablative treatment. Because the plane of resection during endoscopic mucosal resection is typically the middle to deep submucosal layer, compared with standard polypectomy, which normally provides resection at a mucosal level, endoscopic mucosal resection offers the advantage of providing en bloc resection specimens for histopathologic analysis. Indications to perform endoscopic mucosal resection are adenoma and small, well-differentiated carcinoma, confined to the mucosa or with minimal invasion to submucosa, and without any invasion to lymphatic channels or vessels. The most frequently reported major complications, such as perforation (0-5%) and bleeding (0.5-6%), may be controlled by endoscopic methods and rarely require surgical treatment. Follow-up postendoscopic mucosal resection is essential because of the risk of neoplastic recurrence.

Insulated-tip knife endoscopic mucosal resection of large colorectal polyps unsuitable for standard polypectomy

OBJECTIVES

Endoscopic mucosal resection (EMR) has been shown to be safe and effective. En bloc resection is often not achieved using conventional EMR. Insulated-tip knife (It-knife) EMR has been recently proposed for early gastric cancer dissection and removal. This study was conducted to evaluate the safety and efficacy in obtaining en bloc resection with It-knife EMR of large colonic lesions not resectable with standard endoscopic techniques.

METHODS

A total of 29 patients (19 men, 10 women, mean age 67.5 yr, range 44-88) were included in the study. Lesions were considered not suitable for standard polypectomy because of large diameter (>3 cm), morphology, and/or position. Lesions were located in the rectum (N = 11), sigmoid: (N = 10), descending: (N = 4), transverse: (N = 2), and hepatic flexure (N = 2). After saline injection, circumferential incision and dissection of the lesions were attempted with the aim of achieving en bloc resection.

RESULTS

En bloc resection was achieved in only 55.1% of the lesions (16 out of 29 patients). In the remaining cases, resection was completed with a piecemeal technique. The median size of the en bloc resected specimen was 3 x 3.4 cm. Complications occurred in four patients (13.7%). At histopathology, 13 patients had low-grade dysplasia, 15 high-grade dysplasia. One patient had a tumor invading the submucosa and was submitted to surgery.

CONCLUSIONS

It-knife EMR is a promising technique for attempting en bloc resection of large colonic polyps. Adequate training and caution are required because it can be associated with a higher complication rate than with other EMR modalities.