Aims Severe central submucosal fibrosis can make endoscopic resection (ER) of large benign
colorectal polyps with a significant sessile component extremely challenging, with
no identifiable submucosal plane to facilitate endoscopic mucosal resection (EMR)
or endoscopic submucosal dissection (ESD). The PETAL procedure involves isolating
the central fibrotic area at the base of the sessile nodule with wide field EMR, fulgurating
the remnant central polyp with argon plasma coagulation (APC), followed by forceps
avulsion with repeat APC ablation (ACA).
Methods A retrospective study of all patients between January 2015 and December 2023 who
underwent ER of colorectal polyps>20mm was performed. All patients who underwent the
novel PETAL procedure were identified.
Results 37 procedures were identified. Median polyp size was 60mm (range 30-85mm). Delayed
bleeding occurred in 1 case (2.7%), requiring rehospitalisation and repeat endoscopy
but no blood transfusion. There were no incidences of deep mural injury or perforation.
Histopathology showed low-grade dysplasia in 17 (45.9%), high-grade dysplasia in 18
(48.6%), and adenocarcinoma in 2 cases (4%). Follow-up data was available for 89.2%.
Recurrence at first follow-up was seen in 20/33 (60%), but successful eradication
improved to 30/33 (90.9%) and 31/33 (93.9%) at second and third follow-up, respectively.
Both patients found to have adenocarcinoma opted for endoscopic surveillance only,
with no recurrence seen at 3 year follow-up. 2 cases were referred for surgery for
non-endoscopically manageable benign recurrence.
Conclusions The novel PETAL procedure is a safe and effective technique for managing large, benign
colorectal polyps with severe fibrosis. Whilst recurrence at first follow-up is high,
this is usually endoscopically manageable.
