Reply to Matsushita

We have read the letter from Matsushita et al. and appreciate their concerns regarding our previous publication in Endoscopy [1].

The removal of a large pedunculated colon polyp poses a challenge to endoscopists. In the limited space in the bowel lumen, it is a problem to apply prophylactic devices on the stalk to prevent wound bleeding post-resection. An additional problem is applying a diathermic snare through the large head of the polyp to an appropriate level of the stalk for resection. Because of the wide stalk in our case, a prophylactic technique using a detachable loop was a reliable method for preventing wound bleeding, despite the nylon-loop being difficult to maneuver in these circumstances.

Various techniques have been developed to make polyp removal safe and effective for lumen-occluded colon polyps, including the dual-endoscope method [2], resection through the double-channel method [3] [4], and using devices such as needle-knives and dual-knives to replace traditional diathermic snares to directly cut the stalk [5] [6].

We agree with the comment by Matsushita et al. regarding the use of two-channel endoscopy in such patients. However, in our experience, it is not always easy to maneuver the two devices independently through one scope. For instance, after the forceps pass through the open detachable loop or snare and grasp the polyp, attempts to retract the polyp into the loop or snare by flexing the scope tip result in the same movement by the loop or snare, making it difficult to use the loop or snare to capture the polyp at the correct level of the stalk. This problem may be overcome by concurrent insertion or by pulling the accessories through the working channels to adjust the relative proper location rather than only deflecting the scope tip. More practice is needed when using the two-channel endoscopy method.

• References

• 1 Yang CW, Yen HH. Combined biopsy forceps and scissor forceps facilitate cutting the detachable loop entrapped in a large pedunculated polyp. Endoscopy 2012; 44: E202-E203
• 2 Ng AJ, Korsten MA. The difficult polypectomy: description of a new dual-endoscope technique. Gastrointest Endosc 2002; 55: 430-432
• 3 Valentine JF. Double-channel endoscopic polypectomy technique for the removal of large pedunculated polyps. Gastrointest Endosc 1998; 48: 314-316
• 4 Akahoshi K, Kojima H, Fujimaru T et al. Grasping forceps assisted endoscopic resection of large pedunculated GI polypoid lesions. Gastrointest Endosc 1999; 50: 95-98
• 5 Kim BC, Cheon JH, Lee SK et al. Needle knife-assisted endoscopic polypectomy for a large inflammatory fibroid colon polyp by making its stalk into an omega shape using an endoloop. Yonsei Med J 2008; 49: 680-686
• 6 Yang CW, Yen HH. Novel use of combined Dual Knife and endoloop for resection of a large pedunculated colon polyp. Endoscopy 2011; 43: E192