Successful new therapeutic strategies for giant pedunculated colorectal polyps with thick stalks: a case series study

Aims Endoscopic resection of giant pedunculated colorectal polyps (PCPs) with large heads with thick stalks can be technically difficult with conventional snare polypectomy. It involves the risk of clinically severe bleeding. The European Society of Gastrointestinal Endoscopy guidelines recommend pretreatment of the stalk with a dilute epinephrine injection or mechanical hemostasis (prophylactic clip and endoloop application) for PCPs. However, some cases with large tumor heads and thick stalks are associated with challenging operability and poor visibility; therefore, pretreatment can be difficult and not effective. Therefore, we developed a new method for managing intraoperative bleeding during colorectal endoscopic submucosal dissection (ESD) of PCPs with thick stalks.

Methods The strategy is ’’ESD with traction clip fixation and vessel clamping method’’. At first, we created an incision from the anal side of the tumor using a needle-type knife. After exposing the anal side, a novel clip-band device (SureClip traction band; MICRO-TECH) was attached to the stalk, and the other end of the elastic ring was hooked by the SureClip and clipped to the anal side of the intestinal tract. The artery inside the stalk should be carefully dissected to avoid damage. Finally, we applied two clips to clamp the central tissue containing the thick vessels and cutting between the two clips was performed to completely stop bleeding.

We retrospectively analyzed eight consecutive colorectal cancers from April to October 2023 in our Endoscopy unit. Of these, the clinicopathological characteristics and treatment outcomes were analyzed.

Results We had eight cases performed ESD using this method. Among the 8 patients enrolled, 6 were males (75%), mean age 68±7 years. The overall R0 resection rate, median tumor head size and procedure time were 100%, 41 mm (range, 30 – 60 mm) and 32 minutes (range, 20 – 55minutes). No major intra-/peri-procedural or delayed complications occurred. [1] [2] [3]

Conclusions This case series indicate that planned this treatment strategies are essential to the prevention of intraoperative complications associated with giant PCPs with thick stalks. Here, we present successful cases of ESD using this novel method with movie.

 

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Conflicts of interest

Authors do not have any conflict of interest to disclose.

• References

• 1 Choi YS, Lee JB, Lee EJ. et al. Can endoscopic submucosal dissection technique be an alternative treatment option for a difficult giant (≥30 mm) pedunculated colorectal polyp?. Dis Colon Rectum 2013; 56: 660-666
• 2 Ji JS, Lee SW, Kim TH. et al. Comparison of prophylactic clip and endoloop application for the prevention of postpolypectomy bleeding in pedunculated colonic polyps: a prospective, randomized, multicenter study. Endoscopy 2014; 46: 598-604
• 3 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297

Publikationsverlauf

Artikel online veröffentlicht:
15. April 2024