Pedunculated Colon Polyps Research Articles

ENDOSCOPIC SUBMUCOSAL DISSECTION OF COLORECTAL PEDUNCULATED POLYPS

Background: For pedunculated colon polyps, en bloc resection with inclusion of the polyp stalk is necessary to yield an accurate histologic staging. This can be challenging in cases of large polyp and/ or broad stalk using conventional snare resection. We evaluated the feasibility of Endoscopic submucosal dissection (ESD) for large pedunculated polyps with broad stalks. Methods: Between 02-2019 and 11-2021 all patients with large pedunculated polyps defined as polyp diameter ≥ 20 mm and or a broad stalk >5mm were enrolled in the study. All polyps were resected in ESD technique with dissection of the polyp stalk at the base after injection. Results: 25 patients (male=18, age mean:67 years) were included. En bloc resection was achieved in 100% (25/25 of polyps) of the patients. Polyps were mainly located in the sigmoid (n=19), rectum (n=3).Median size of polyps was 30*25*17 mm Histologic examination revealed the following results: Adenoma Low-Grade Intraepithelial Neoplasia (LG-IEN): 9; High-Grade Intraepithelial Neoplasia (HG-IEN): 7, pTis: 3, Adenoarcinoma: 5 (G1, pT1, L0, V0, Haggitt 3: 2/G2, pT1, L0, V0, Haggitt 3:2/G3, pT1, Bd3, V1, Haggitt 4: 1); Other:1. R0 resection rate was 100% and the curative resection rate yielded 96% (24/25) without severe adverse events. Conclusions: ESD achieved a high en bloc and R0 resection rate of large pedunculated polyps. In our collective, up to 32% of polyps already had adenocarcinoma resulting in a high curative resection rate due to complete resection and subsequently accurate risk classification.

A case of pedunculated colonic polyp that was difficult to differentiate from active bleeding on enhanced computed tomography

A case of pedunculated colonic polyp that was difficult to differentiate from active bleeding on enhanced computed tomography

Bleeding Risk With Cold Snare Polypectomy of ≤10 mm Pedunculated Colon Polyps.

Pedunculated polyps (PPs) in the colon are usually resected with hot snare polypectomy to prevent immediate postpolypectomy bleeding (IPPB). This study aimed to evaluate the safety of CSP of <10 mm PPs. Patients undergoing colonoscopy from February 18, 2019, to April 24, 2020, and were found to have at least 1 ≤10 mm PP resected with CSP were included prospectively in a continuous quality improvement project to assess the risk of IPPB and delayed postpolypectomy bleeding. Polyp location, size, and pathology, as well as the method of resection, were recorded. In addition, we assessed the occurrence and severity of IPPB and the need for intervention. We found 239 eligible polyps in 182 patients. The mean (SD) age was 58.8 (8.3) years, and 61% were males. IPPB occurred in 72 of 239 polyps, corresponding to a per-polyp bleeding percentage of 30.1% and in 65 of 182 patients, equating to a per-patient bleeding rate of 35.7%. We successfully treated bleeding by endoscopic hemostasis in 57%; the remaining 31 polyps (43%) did not require endoscopic intervention. There was no association between IPPB with age, gender, or use of aspirin or antithrombotic agents. In the bivariate model, polyp size and pathology were not associated with the risk of IPPB. Right-sided polyps were associated with a reduced risk of IPPB in the bivariate model by 61% (odds ratio=0.39; 95% confidence interval, 0.21-0.74;P=0.0057). In the multivariate model, choking the polyp base decreased the likelihood of IPPB by 97% (odds ratio=0.03; 95% confidence interval, 0.00-0.86;P=0.0459). There were no instances of delayed bleeding, perforation, or postpolypectomy syndrome. CSP can be used for resection of ≤10 mm PPs. It is associated with a lower risk of immediate bleeding than the common perception among gastroenterologists.

Endoscopic characteristics influencing postpolypectomy bleeding in 1147 consecutive pedunculated colonic polyps: a multicenter retrospective study

Postpolypectomy bleeding is the most common adverse event with pedunculated polyps. We clarified the endoscopic characteristics influencing postpolypectomy bleeding for pedunculated colonic polyps. We reviewed clinical data for 1147 pedunculated colonic polyps removed by polypectomy in 5 Japanese institutions. Pedunculated polyps were defined as polyps with a stalk length≥5mm. Analyzed clinical data were age, sex, polyp location/size, stalk length/width, prophylactic clipping or endoloop before polypectomy, injecting the stalk, closing the polypectomy site, antithrombotic agent use, and endoscopist experience. Postpolypectomy bleeding was classified as immediate bleeding or delayed bleeding. Immediate and delayed bleeding was observed in 8.5% (97/1147) and 2% (23/1147) of polypectomies, respectively. Comparing immediate bleeding with nonbleeding, multivariate analysis showed that stalk width≥6mm (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.4) was a significant risk factor for immediate bleeding. For polyp size≥15mm, prophylactic endoloop use (OR, .17; 95% CI, .04-.72) was a significant inhibiting factor. Comparing delayed bleeding with nonbleeding, multivariate analysis showed that prophylactic clipping before polypectomy (OR, 4.2; 95% CI, 1.3-13) and injecting the stalk (OR, 4.0; 95% CI, 1.4-12) were significant risk factors for delayed bleeding. The increased risk for delayed bleeding with injecting the stalk and prophylactic clipping before polypectomy suggests that simple resection with coagulation mode is a suitable strategy in endoscopic resection of pedunculated polyps. Moreover, prophylactic endoloop use was highly likely to inhibit immediate bleeding with polyp size≥15mm.

Effect of prophylactic clip application for the prevention of postpolypectomy bleeding of large pedunculated colonic polyps: a randomized controlled trial

Prophylactic application of a hemoclip has been suggested as an alternative to the use of an endoloop for the prevention of postpolypectomy bleeding (PPB) when resecting large, pedunculated colorectal polyps. Therefore, this multicenter, randomized controlled trial investigated the efficacy of prophylactic hemoclip application to reduce PPB during the resection of large pedunculated polyps. Large pedunculated polyps (≥10mm in head diameter) were eligible for inclusion. Polyps were randomized into a study arm (where clips were applied before resection) and a control arm (without pretreatment). The primary outcome was the rate of PPB in each group. PPB included immediate PPB (IPPB) and delayed PPB (DPPB). IPPB was defined as blood oozing (≥1 minute) or active spurting occurring immediately after polyp resection. DPPB was defined as rectal bleeding, occurring after completion of the colonoscopy. In total, 238 polyps from 204 patients were randomized into the clip arm (119 polyps) or the control arm (119 polyps). Overall bleeding adverse events were observed in 20 cases (IPPB, 16; DPPB, 4). The rate of overall PPB, IPPB, and DPPB was 8.4%, 6.7%, and 1.7%, respectively, for all polyps. The rate of overall PPB (clip 4.2% vs control 12.6%, P= .033) and IPPB (clip 2.5% vs control 10.9%, P= .017) was significantly lower in the clip arm than the control arm. Prophylactic clipping before resecting large pedunculated polyps can reduce overall PPB and IPPB compared with no prior treatment. Therefore, prophylactic clipping may be considered before resection of large pedunculated polyps. (Clinical trial registration number: NCT02156193.).

A novel technique using endoscopic band ligation for removal of long-stalked (>10 mm) pedunculated colon polyps: A prospective pilot study.

Background:Endoscopic removal of large and thick-stalked pedunculated colonic polyps, often leads to massive hemorrhage. Several techniques to minimize this complication have not been widely adopted due to some caveats. In order to prevent postpolypectomy bleeding, we invented a novel technique to dissect long-stalked pedunculated colonic polyps using endoscopic band ligation (EBL) by laterally approaching the stalk.Methods:In this prospective single-center study, 17 pedunculated polyps in 15 patients were removed between April 2012 and January 2016. We targeted pedunculated polyps with a long stalk length (>10 mm) and a large head (>10 mm) located in the distal colon. After identifying lesions with a colonoscope, we reapproached the middle part of the stalk of the targeted polyp with an EBL-equipped gastroscope to ligate it. Snare polypectomy was performed just above the ligation site of the stalk.Results:EBL-assisted polypectomy removed all of the lesions successfully, which were confirmed pathologically. There was little technical difficulty associated with the endoscopic procedures, regardless of polyp size and stalk thickness, except for one case with a very large polyp that impeded the visualization of the ligation site. We observed a positive correlation between procedure time and the diameter of the head (spearman ρ = 0.52, P = 0.034). After dissection of the polyp, the EBL bands remained fastened to the dissected stalks in all cases. There was no complication associated with polypectomy for 1 month.Conclusion:EBL-assisted polypectomy is an easy, safe, and effective technique to remove long-stalked pedunculated colonic polyps without postpolypectomy bleeding.

Cancer in a polyp of the large intestine - an interdisciplinary decision problem.

Large intestine polyps are commonly found during colonoscopies. Pedunculated colon polyps can be totally removed using an endoscopic invasive technique. A problem arises when the pendulated polyp contains cancerous infiltration. The aim of the article was a presentation of the clinical decision process concerned with the presence of cancer invasion tissue within colorectal polyps. Review of literature source and presentation of histological sample photography. A correct interpretation of the pathomorphological protocol is crucial for the therapeutic decision, which should be consistent with the actual recommendations of gastroenterological societies. Local treatment is considered as complete when the adenocarcinoma is well or moderately differentiated without any microinvasion of blood and lymphatic vessels and the resection margin is more than 1 mm from the cancer tissue infiltration. In the contemporary clinical practice patients with a colon polyp require rational clinical decisions, which are based on the actual recommendations.

Endoscopic resection of large pedunculated colon polyps using only a scissor-type knife: a case series.

Background and AimsAll pedunculated colon polyps (PCPs) should ideally be resected en bloc for accurate histopathological evaluation. However, maneuvering a snare around the large head of a pedunculated polyp with a long, wide stalk can be technically challenging. In addition, clinically significant bleeding after snare polypectomy remains a legitimate concern. Small case series from Asia have supported the feasibility of endoscopic submucosal dissection (ESD) for the removal of these challenging large PCPs. However, ESD is not widely performed in the West because of its technical complexity, steep learning curve, and higher risk of adverse events when compared with conventional endoscopic mucosal resection. Our aim was to demonstrate the feasibility of performing en bloc resection of large PCPs using a scissor-type electrocautery ESD knife when conventional snare polypectomy is not feasible.MethodsTwo patients were found to have large PCPs with wide stalks. Attempts to maneuver a snare around the head of the PCP were unsuccessful, and the decision was to proceed with ESD using the scissor-type knifeResultsBoth polyps were successfully resected en bloc using only the scissor-type knife. Both procedures were completed in under 20 minutes with no adverse events. Histopathology results of both polyps were consistent with tubulovillous adenoma with resection margins free of dysplasia, consistent with curative R0 resection.ConclusionEn bloc resection of large PCPs can be challenging when it is difficult to maneuver the snare around the head of the polyp. In this video, we demonstrate how a dedicated scissor-type ESD knife can facilitate the resection of these lesions. The insulated rotatable blades of the scissor-type knife allow safe and precise dissection of the stalk under direct visualization, which further permits targeted hemostasis when needed. Future studies are needed to corroborate the efficacy and safety of this device for the resection of selected colorectal lesions.

Colon cancer of Peutz-Jeghers syndrome with gallolyticus endocarditis

We report a case of Peutz-Jeghers syndrome with gallolyticus endocarditis which has not yet been reported. Colon cancer was observed and implicated in Peutz-Jeghers syndrome. A 44-year-old female with fever and heart murmur was diagnosed as infective endocarditis caused by streptococcus gallolyticus. After treatment with antibiotics and mitral valbuloplasty, we performed gastrointestinal endoscopic studies and found polyps in stomach and colon. Histological findings of a large pedunculated colon polyp revealed hamartomatous polyp with a lesion of adenocarcinoma with adenoma. She had pigmentation of digits. Her father had also digits pigmentation and died of pancreas cancer. Peutz-Jeghers syndrome with colon cancer was incidentally diagnosed by infective endocarditis and subsequent colonoscopy.

A Technique Using EBL for Removal of Pedunculated Colon Polyps

A Technique Using EBL for Removal of Pedunculated Colon Polyps

Tu1945 A NOVEL TECHNIQUE USING ENDOSCOPIC BAND LIGATION FOR REMOVAL OF LONG-STALKED PEDUNCULATED COLON POLYP

Bleeding is the most common complication associated with polypectomy of large pedunculated colonic polyp. Although several techniques have been developed to minimize bleeding, none of these methods has become the gold standard. To prevent post-polypectomy bleeding effectively, we developed and attempted a new endoscopic technique for removal of large long-stalked pedunculated colonic polyps using band ligations.

Snare polypectomy in pedunculated colonic polyp

A 55-year-old man with a familial history of colonic neoplasm presented for screening colonoscopy, he had no specific symptomatology, physical examination finding and biological exams were normal.

Endoscopic resection using the Clutch Cutter and a detachable snare for large pedunculated colonic polyps.

Background and study aims Endoscopic snare polypectomy with prophylactic detachable snare of large pedunculated colonic polyps (PCPs) is technically demanding. To facilitate removal of such polyps, we developed endoscopic resection using the Clutch Cutter and a detachable snare (ERCCDS). This study aimed to evaluate the efficacy and safety of the procedure. Patients and methods From April 2010 to July 2015, 14 consecutive patients who had PCPs with head > 10 mm, stalk width > 5 mm, and stalk length > 10 mm were enrolled in this single-center prospective uncontrolled study. They were treated using ERCCDS by a single endoscopist. The efficacy and safety were assessed using a database prospectively formatted from the medical records. Results The Clutch Cutter was able to cut the distal side of the stalk an adequate distance from the detachable snare under good visual control. R0 resections were obtained in all lesions. There were no immediate or delayed complications. Conclusions ERCCDS appears to be a safe, easy, and technically efficient method for large PCPs, although larger studies are needed to compare ERCCDS and standard resection.

Morphometric study of the blood supply of pedunculated colon polyps: What is the optimal position on the stalk for snare resection?

Background and study aims: Bleeding after colonoscopic resection of pedunculated polyps cannot be easily predicted. The aims of this study were to evaluate the blood supply in pedunculated polyps and to clarify the optimal position on the polyp stalk for snare placement to prevent post-polypectomy hemorrhage. ]Patients and methods: In one institution, 11 pedunculated polyps from 11 patients were studied prospectively. All polyps were resected at the base of the stalk using a snare wire with electrocautery. Histologic axial sections from the apex and base of the stalk were examined with hematoxylin eosin and elastica stains. Elastica stains were used to identify blood vessels. The cross-sectional area of the stalk, total vessel area, maximum diameter of artery/arteriole lumen, number of thick (≥ 0.1 mm) vessels, and number of arteries/arterioles were measured in each section with image processing software. Wilcoxon signed-ranks test was used for comparison. Results: The median polyp diameter was 16 mm (range 7 to 24 mm) and median length of the stalk was 11 mm (range 7 to 23 mm). Two invasive cancers (T1) were included. The maximum diameter of the arterial/arteriolar lumen was greater at the base (P = 0.0044), whereas the ratio of the vessel area to the cross-section area was greater at the apex (P = 0.016). The number of thick vessels and arteries/arterioles were equivalent between apex and base. Conclusions: Morphometric study of the blood supply of pedunculated polyps confirmed that the optimal site for the excision of pedunculated polyps is in the middle of the stalk.

Comparison of clipping with and without epinephrine injection for the prevention of post-polypectomy bleeding in pedunculated colon polyps.

Post-polypectomy bleeding (PPB) is the most common adverse event of colonoscopic polypectomy, especially in cases with large pedunculated polyps. To minimize the risk of PPB, several endoscopic preventive methods have been performed. The aim of this prospective, randomized study was to compare the rates of PPB following single (clipping alone) and combined (clipping plus epinephrine-saline injection) methods in prevention of PPB in large pedunculated polyps. Adult patients with pedunculated colorectal polyps with heads ≥ 10 mm were prospectively enrolled from March 2011 to January 2013. Patients were randomized to receive treatment of either clips alone (group A) or clips plus injection of epinephrine-saline (group B) prior to a conventional polypectomy. PPB rate in both groups were compared. A total of 148 patients with 173 pedunculated colorectal polyps were enrolled. Groups A and B each had 74 patients, with 83 and 90 polyps, respectively. The mean head diameters were 17.2 ± 6.6 and 17.5 ± 6.7 mm in groups A and B, respectively (P = 0.748). Immediate PPB (IPPB) occurred in 10 cases (12.0%) from group A and 13 cases (14.4%) from group B (P = 0.64). There were no cases of delayed PPB or perforation. Multivariate analysis showed that inadequate bowel preparation and large head diameter of polyp were independent risk factors for IPPB. The rate of IPPB is relatively high in cases with large pedunculated polyps, but these polyps can be successfully resected by snare polypectomy following use of the single prophylactic clipping method.

Comparison of clipping with and without epinephrine injection for the prevention of post-polypectomy bleeding in pedunculated colon polyps

Comparison of clipping with and without epinephrine injection for the prevention of post-polypectomy bleeding in pedunculated colon polyps

Comparison of prophylactic clip and endoloop application for the prevention of postpolypectomy bleeding in pedunculated colonic polyps: a prospective, randomized, multicenter study

Comparison of prophylactic clip and endoloop application for the prevention of postpolypectomy bleeding in pedunculated colonic polyps: a prospective, randomized, multicenter study

Insulated-tip knife endoscopic resection of a giant pedunculated colon polyp

Insulated-tip knife endoscopic resection of a giant pedunculated colon polyp

Follicular Dendritic Cell Sarcoma of the Inflammatory Pseudotumor-like Variant Presenting as a Colonic Polyp.

Follicular dendritic cell (FDC) sarcoma is rare and is classified either as conventional type or inflammatory pseudotumor (IPT)-like variant. Extranodal presentation is uncommon and nearly all gastrointestinal FDC tumors are of the conventional type. IPT-like variant tumors occur almost exclusively in the liver and spleen and are consistently associated with Epstein-Barr virus (EBV). Here we report the case of a 78-year-old woman with an IPT-like FDC sarcoma presenting as a pedunculated colonic polyp. Histologically, scanty atypical ovoid to spindle cells were mixed with a background of florid lymphoplasmacytic infiltrate, which led to an initial misdiagnosis of pseudolymphoma. These atypical cells expressed CD21, CD23, CD35, and D2-40, and were positive for EBV by in situ hybridization, confirming the diagnosis. The patient was free of disease five months after polypectomy without adjuvant therapy. Although extremely rare, the differential diagnosis for colonic polyp should include FDC sarcoma to avoid an erroneous diagnosis. A review of the 24 cases of IPT-like FDC sarcoma reported in the literature reveal that this tumor occurs predominantly in females with a predilection for liver and spleen, and has a strong association with EBV.

Endoloop-Assisted Polypectomy Technique

Endoscopic resection of large pedunculated colon polyps should be preferred over surgical resection; however, it carries the risk of associated significant postpolypectomy bleeding. With advances in endoscopic tools such as endoclips and endoloops, it has become safer to perform endoscopic resection of large pedunculated polyps. Herein are demonstrated some important aspects of the technique for endoscopic resection of a large pedunculated colon polyp. This article is part of an expert video encyclopedia.