Peutz-Jeghers polypectomy in the small bowel using “ligate-and-let-go” technique

The “ligate-and-let-go” polypectomy technique involves looping a target lesion with a detachable snare and letting it necrose and slough off [1]. This technique is thought to carry less risk for bleeding and perforation than electrocautery. We present a case of a patient with Peutz-Jeghers syndrome in which the “ligate-and-let-go” method was used to successfully treat an obstructing small bowel polyp via anterograde double-balloon enteroscopy (DBE). To our knowledge, this is the first utilization of this technique to successfully remove a jejunal polyp via anterograde DBE.

A 46-year-old woman with Peutz-Jeghers syndrome was found to have a large polyp and early intussusception on computed tomography (CT) enterography ([Fig. 1]). Anterograde DBE confirmed a 25-mm pedunculated polyp in the distal jejunum ([Fig. 2 a]). Biopsies were obtained and the region was tattooed with India ink. Pathology revealed a hamartomatous polyp without dysplasia. During repeat anterograde DBE, a ligature was successfully placed at the neck of the polyp via an endoloop device ([Fig. 2 b]). Given the high position of the loop, the decision was made to proceed with the “ligate-and-let-go” technique to avoid bleeding and incomplete resection ([Video 1]). Repeat anterograde DBE 5 weeks later revealed a well-healed scar in the distal jejunum at the site of the ligated polyp as identified by prior tattoo ([Fig. 3]).

Fig. 1 Computed tomography enterogram of the abdomen revealing a large polyp within the small bowel with dilated proximal bowel loops concerning for intussusception.

Fig. 2 a The 25-mm pedunculated polyp in the distal jejunum prior to ligation. b Pedunculated jejunal polyp with ligature placed high on the polyp neck.

Video 1 Anterograde double-balloon endoscopy of small bowel with utilization of “ligate-and-let-go” technique to remove pedunculated jejunal polyp. Repeat procedure 5 weeks later showed well-healed scar at the site of the prior polyp.

Fig. 3 Well-healed jejunal mucosa at the site of the polyp post-ligation. India ink tattoo can be seen surrounding the scar tissue.

The “ligate-and-let-go” technique offers successful polypectomy with a low risk of bleeding and perforation. There is one published report of use of this technique via single-balloon enteroscopy to remove a distal ileal lipoma, though there is otherwise little data regarding its use in the small bowel [2]. To our knowledge, this was the first case of using this technique via anterograde DBE to successfully remove a jejunal hamartoma in a patient with Peutz-Jeghers syndrome. Often these patients may have multiple polyps requiring surveillance and intervention; this approach offers an alternative to resection and removal.

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Publication History

Article published online:
15 December 2021

• References

• 1 Friedland S, Kahng LS, Torosis J. et al. Ligate and let go. Gastrointest Endosc 2003; 58: 473-474
• 2 Veloso R, Pinho R, Rodriques A. et al. Endoloop ligation (“loop-and-let-go”) of a large ileal lipoma by balloon-assisted enteroscopy. Endoscopy 2012; 44: E176