ORIGINAL ARTICLE
Use of Dual Knife for Large Pedunculated Colorectal Polyps Chia-Wei Yang, MD,* Hsu-Heng Yen, MD,*w Yang-Yuan Chen, MD,z and Maw-Soan Soon, MD*
Background: Endoscopic resection of large pedunculated colorectal polyps is technically difficult, especially when the polyps are so large that it is either not possible or too difficult to resect them using a conventional polypectomy snare.
be useful and safe.5 Here we describe our subsequent experience in the endoscopic management of large pedunculated colonic polyps using this novel technique and evaluate the safety, efficacy, complications, and limitations of this technique.
Aim: To facilitate the removal of pedunculated colorectal polyps, we developed a new technique using a combination of a dual knife and preventive hemostatic procedures. Methods: Nine patients (5 men and 4 women; mean age, 59.8 y; range, 49 to 79 y) with pedunculated polyps >2 cm in diameter were treated with this technique. A dual knife and endoclips or an endoloop were used as needed. Results: All lesions, except for 1 polyp, were resected endoscopically. The mean time for complete resection was 8.5 minutes (range, 1.5 to 16 min). The procedure time decreased significantly after the fifth case (168 vs. 746 s, P = 0.0009). No hemorrhage, perforation, or other complications occurred during follow-up among the endoscopically resected cases. Conclusions: Combined use of a dual knife and prophylactic hemostatic procedures is a feasible alternative technique for removing large pedunculated colorectal polyps when conventional snare resection is impossible or difficult. Key Words: endoscopy, colon, colon polyp, colon cancer, polypectomy, knife
(Surg Laparosc Endosc Percutan Tech 2014;24:444–447)
E
ndoscopic polypectomy is an established procedure for resecting colorectal polyps, which can also prevent colorectal cancer.1 The use of a conventional diathermic snare is limited for en bloc resection when the polyp diameter is nearly equal to or larger than the diameter of the snare. Piecemeal snaring of a large pedunculated colonic polyp is an alternative technique.2,3 However, this option may be unacceptable because of the increased risk of bleeding and the inability to conduct adequate pathologic examinations in cases of suspected malignancy.4 The removal of large or lumen-occupying pedunculated colonic polyps is a great challenge for endoscopists and the patient might require referral for surgical management. We previously reported our first experience with using a dual knife to remove 1 such lesion and found it to
Received for publication December 28, 2011; accepted September 20, 2012. From the *Department of Gastroenterology, Changhua Christian Hospital, Changhua; wSchool of Medicine, Chung-Shan Medical University, Taichung City; and zDepartment of Gastroenterology, China Medical University Hospital, Taichung City, Taiwan. The authors declare no conflicts of interest. Reprints: Hsu-Heng Yen, MD, Department of Gastroenterology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua 500, Taiwan (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
444 | www.surgical-laparoscopy.com
PATIENTS AND METHODS Patients A retrospective analysis of the endoscopy database identified 9 patients (5 men and 4 women; mean age, 59.8 y; range, 49 to 79 y) with 9 pedunculated colonic polyps over a 15-month period (July 2010 to November 2011) were included in this study. The diameters of their polyps were Z2 cm as measured using open biopsy forceps. These polyps were evaluated by both authors (H.-H. Y and C.-W. Y) who had experience with performing >500 colonoscopies per year for 5 years. They determined that a 1-step resection using a standard snare resection technique was not possible. Standard piecemeal resection or alternative dual knife–assisted resections were discussed with the patients before enrollment into this study. The study was carried out in accordance with the Helsinki Declaration. Written informed consent was obtained from all patients for the procedures that were performed. Patients receiving anticoagulant or antiplatelet therapy for cardiovascular diseases were instructed to discontinue the use of these drugs at least 5 days before the endoscopic procedure after consultations with a cardiologist and hematologist. Their medications were resumed if there were no signs of bleeding within 1 day of resection. Patients on hemodialysis were managed with heparin-free dialysis for 1 week before and after resection. All patients were evaluated for their coagulation profiles, including complete blood count, prothrombin time, and activated partial thromboplastin time.
Techniques and Equipment The cleansing of the bowel was performed by ingestion of a polyethylene glycol electrolyte lavage solution. After this, all patients received conscious sedation by administration of midazolam (2 to 5 mg) and meperidine (25 to 50 mg). To facilitate manipulation of the dual knife for colonic polyp resection, endoscopy was performed using a gastroscope (GIF-H260; Olympus, Tokyo, Japan) for a distal site of the colonic polyp or a colonscope (PCFQ260JL; Olympus) for a proximal site of the colonic polyp. To safely resect the polyp, prophylactic hemostatic procedures were applied before the resection, such as those using Endoclips (HX-600-135; Olympus) or a detachable Endoloop (MAJ-254; Olympus). If possible, we preferred using the endoloop over a polyp stalk with an estimated diameter of >1 cm because of its greater efficacy in achieving hemostasis and the technical difficulties involved in applying >2 hemoclips. The endoloop was placed and
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tightened until a cyanotic change in the polyp suggested adequate blockage of blood flow. For polyp resection, we used a Dual Knife (KD-650U; Olympus; Fig. 1) with an electrosurgical generator (endocut = 50 W; coagulation 30 W; effect 2; ICC = 200; ERBE Co., Tubingen, Germany). The knife length was 1.5 mm. The knife could be fixed in either an extended position for cutting the stalk above the ligation position by at least 3 mm under direct visualization or in a retracted position for coagulation when resection-related bleeding was encountered (Figs. 2–4). The procedure time recorded the interval between the passage of the Dual Knife through the working channel and stopped after complete resection of the polyp. The technique for using the dual knife for resecting the stalk, similar to using a needle knife, initially involves moving from the lateral side to the central area parallel to the bowel wall where the polyp is located. If needed, although not routinely recommended because of the risk of bowel wall injury behind the stalk, the knife can be pushed onto the stalk while carefully cutting from the proximal part forward to the distal part. This cutting forward maneuver should only be applied when a thick stalk is encountered, and should be performed more cautiously when using a needle knife because of the long knife tip (4 to 7 mm) of commercial devices compared with the Dual Knife [1.5 mm of model KD-650 Q/U used for esophageal and colorectal endoscopic submucosal dissection (ESD) and 2 mm of model KD-650 L used for gastric ESD]. This makes it difficult to control the knife accurately, especially in a narrow space. We use the dual knife in its retracted position with 0.3 mm of its needle tip exposed for coagulation to avoid excessive bowel wall injury. After resection, the polyp was captured using a basket catheter, and if possible, gently extracted through the anus or dragged to the rectum for spontaneous passage. We measured the absolute maximum diameter of the polyp head and stalk after its retrieval or spontaneous passage.
Histologic Examination Polyps were fixed in 10% formalin and then stained with hematoxylin and eosin for histopathologic assessment. Colorectal adenomas were histologically classified according to the World Health Organization Classification of
FIGURE 1. Dual knife: a 1.5 mm knife with a knob over its tip when in its extended position (left) and only 0.3 mm of its needle tip exposed in its retracted position (right). r
2014 Lippincott Williams & Wilkins
Endoscopic Resection for Large Polyps
FIGURE 2. A large pedunculated polyp in the descending colon (case 6).
Tumors.6 If cancer was detected, a decision for further aggressive surgical management was taken based on the level of cancer invasion. According to Haggitt classification,7 pedunculated polyps with carcinoma invading the head, neck, or stalk require no further treatment when the resection margins are free of cancer and there is no lymphatic or vascular invasion. Additional radical surgery was reserved for those polyps with carcinoma that had invaded into the submucosa of the bowel wall below the polyp stalk because of an increased risk of lymph node metastases.
Follow-up Evaluation If no complications occurred after the endoscopic procedure, the patients were discharged with a scheduled follow-up of at least 1 telephone contact within 3 days and a return to our outpatient services 1 week later. According to our institutional guideline, patients with malignant polyp without the need for surgery were scheduled for a follow-up colonoscopy 1 and 6 months later. For patients with
FIGURE 3. After applying 1 endoloop, the polyp became cyanotic above the level of ligation, thus ensuring sufficient tightening.
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decreased significantly after the fifth case (first 4 resected cases vs. last resected cases: 746 vs. 168 s, P = 0.0009). All polyps were adenomas; 4 patients had carcinomas arising in tubulovillous adenomas. These carcinomas were confined to the polyp head or stalk and their resection margins were free of cancer, thereby not requiring any further surgery. All patients who received complete endoscopic management had no delayed hemorrhage, perforation, or other complications for at least 3 months. The results are summarized in Table 1.
DISCUSSION
FIGURE 4. Use of a dual knife for cutting the polyp stalk above the level of ligation under direct visualization.
adenomas >1 cm, a follow-up colonoscopy was scheduled 6 months later.
RESULTS The clinical outcomes of our 9 patients are summarized in Table 1. All 9 polyps were >2 cm in diameter; the largest was 4 cm in diameter. The stalk diameters were at least 0.8 cm, with a greatest width of 2.5 cm. The locations were most often over the sigmoid colon (5/9 polyps), and the others were in the splenic flexure, the descending colon, and the cecum. The mean time for complete resection after applying the endoloop or endoclips was 8.5 minutes (range, 1.5 to 16 min). Resection failed for 1 patient (case 4). This was due to insufficient tightening of the endoloop because of the limited space for observation in the splenic flexure owing to the large polyp and wide stalk. Active bleeding was observed after the first resection attempt, and this patient was referred for surgical resection. The procedure time
When faced with pedunculated colonic polyps that are difficult to resect by maneuvering a conventional diathermic snare because of an occluded lumen or a polyp head size larger than the snare, stalk resection using a specialized device is an alternative technique. To remove these lesions en bloc, reported resection techniques include using a needle knife,8–10 an insulated-tip diathermy knife,11 or a grasping-type scissors forceps.12 In this study; we report the use of a dual knife as an alternative technique to remove large pedunculated colorectal polyps. The dual knife, a recently developed instrument for ESD,13 resembles a short needle knife with a knob-shaped tip. The small knob-shaped tip is useful for marking and for hemostasis in its retracted position. This feature makes the needle less likely to slip during resection of floppy polyps in its extended position. This results in improved overall knife maneuverability compared with a standard needle knife. In addition, polyps with wide stalks take more time to be resected, and removal of a floppy pedunculated polyp is more technically demanding. A large polyp with a long stalk (our cases 2 and 3) may move relatively freely within the lumen, making it difficult to control the knife during resection. In this situation, using gravity by a position change or placing a transparent cap on the scope can help to control the position of the polyp stalk to facilitate polyp resection. With the increased experience, the procedure time was reduced from 746 to 168 seconds (P = 0.0009) after the fourth successful case. Therefore, our study suggested this new technique is feasible with a short learning curve. The main complication with conventional polypectomy is bleeding, ranging from 0.3% to 6.1% of cases,
TABLE 1. The Clinical Features and Outcomes of our Patients
Polyp Head /Stalk size Location (cm)
Case
Age/ Sex
Ligation Method
Procedure Time
Outcome/ Complication
1 2
58/M 79/F
S S
4.0/2.5 2.5/1.0
EC + EL EC
13 min 45 s 16 min
Success/no Success/no
3
60/F
S
2.1/0.9
EC
9 min 30 s
Success/no
4 5
59/M 49/F
SF S
3.8/2.2 2.5/2.0
EC + EL EL
NA 11 min
Failure/surgery Success/no
6 7 8 9
56/M 61/F 59/M 58/M
D S C S
2.8/1.2 2.2/0.8 2.8/1.0 3.5/1.2
EL EL EL EL
1 min 30 s 3 min 5 min 1 min 45 s
Success/no Success/no Success/no Success/no
Pathology Tubulovillous adenoma Adenocarcinoma from tubulovillous adenoma Adenocarcinoma from tubulovillous adenoma. Tubulovillous adenoma Adenocarcinoma from tubulovillous adenoma Tubular adenoma Tubulovillous adenoma Tubulovillous adenoma Adenocarcinoma from tubulovillous adenoma
C indicates cecum; D, descending colon; EC, endoclip; EL, endoloop; F, female; M, male; NA, not available; S, sigmoid colon; SF, splenic flexure.
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depending on the polyp size, its location, and whether it has a broad base or a wide stalk.14 Therefore, prophylactic hemostatic procedures are required to prevent postpolypectomy hemorrhage. Mechanical hemostatic devices, such as the endoloop15,16 and endoclips,8–10 have been introduced for preventing early or delayed postpolypectomy hemorrhage. The endoloop, measuring 5 3 cm when fully opened, is maneuvered around the tip of the polyp with limited expansible force because of its thin nylon composition. It may be a challenge to fully open the loop in case of limited space, because of the large polyp size or narrow colon lumen diameter, particularly in the left colon or other flexure locations. Of note, it should be cautioned that an adequate distance from the ligated loop should be maintained during cutting to avoid slippage of the loop, which would result in wound bleeding. In addition, it has been reported that transection can be achieved with a sufficiently tightened loop if the stalk diameter is 2 cm). For our failed case, based on the above concepts, we believe that placing an endoloop is a more reliable choice for a polyp with a wide stalk, despite the difficulty involved and the time consumed in maneuvering the endoloop to the stalk because of the large polyp head with a narrow space. It is important to carefully ensure sufficient endoloop tightening by observing the color of the polyp head, which should change to dark red after ligation, and if needed, place another endoloop. In addition, epinephrine injection into the stalk might be another choice to prevent postpolypectomy hemorrhage, if one cannot confidently confirm the efficacy of the former mechanical technique. In conclusion, based on our experience, combined use of a dual knife and an adequate prophylactic hemostatic procedure is a novel, feasible, and alternative technique to conventional endoscopic treatment. It offers en bloc polyp removal in cases where conventional snare resection is impossible or difficult. A future study comparing
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conventional techniques with snare and the technique with Dual Knife is still required. REFERENCES 1. Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993;329:1977–1981. 2. Binmoeller KF, Bohnacker S, Seifert H, et al. Endoscopic snare excision of “giant” colorectal polyps. Gastrointest Endosc. 1996;43:183–188. 3. Stergiou N, Riphaus A, Lange P, et al. Endoscopic snare resection of large colonic polyps: how far can we go? Int J Colorectal Dis. 2003;18:131–135. 4. Kurzon RM, Ortega R, Rywlin AM. The significance of papillary features in polyps of the large intestine. Am J Clin Pathol. 1974;62:447–454. 5. Yang CW, Yen HH. Novel use of combined dual knife and endoloop for resection of a large pedunculated colon polyp. Endoscopy. 2011;43(suppl 2 UCTN):E192. 6. Li ZS, Li Q. The latest 2010 WHO classification of tumors of digestive system. Zhonghua Bing Li Xue Za Zhi. 2011;40: 351–354. 7. Haggitt RC, Glotzbach RE, Soffer EE, et al. Prognostic factors in colorectal carcinomas arising in adenomas: implications for lesions removed by endoscopic polypectomy. Gastroenterology. 1985;89:328–336. 8. Cipolletta L, Bianco MA, Rotondano G, et al. Endoclipassisted resection of large pedunculated colon polyps. Gastrointest Endosc. 1999;50:405–406. 9. Chen YY, Su WW, Soon MS, et al. Hemoclip-assisted polypectomy of large duodenal Brunner’s gland hamartoma. Dig Dis Sci. 2006;51:1670–1672. 10. Luigiano C, Ferrara F, Ghersi S, et al. Endoclip-assisted resection of large pedunculated colorectal polyps: technical aspects and outcome. Dig Dis Sci. 2010;55:1726–1731. 11. Akahoshi K, Kubokawa M, Fujimaru T, et al. Endoscopic resection of a large pedunculated colonic polyp using an insulated-tip diathermy knife. Endoscopy. 2005;37:405–406. 12. 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. 13. Yen HH, Yang CW, Su PY, et al. Use of hemostatic forceps as a preoperative rescue therapy for bleeding peptic ulcers. Surg Laparosc Endosc Percutan Tech. 2011;21:380–382. 14. Rosen L, Bub DS, Reed JF III, et al. Hemorrhage following colonoscopic polypectomy. Dis Colon Rectum. 1993;36:1126–1131. 15. Rey JF, Marek TA. Endo-loop in the prevention of the postpolypectomy bleeding: preliminary results. Gastrointest Endosc. 1997;46:387–389. 16. Katsinelos P, Kountouras J, Paroutoglou G, et al. Endoloopassisted polypectomy for large pedunculated colorectal polyps. Surg Endosc. 2006;20:1257–1261. 17. Shirai M, Nakamura T, Matsuura A, et al. Safer colonoscopic polypectomy with local submucosal injection of hypertonic salineepinephrine solution. Am J Gastroenterol. 1994;89:334–338. 18. Hsieh YH, Lin HJ, Tseng GY, et al. Is submucosal epinephrine injection necessary before polypectomy? A prospective, comparative study. Hepatogastroenterology. 2001;48:1379–1382. 19. Di Giorgio P, De Luca L, Calcagno G, et al. Detachable snare versus epinephrine injection in the prevention of postpolypectomy bleeding: a randomized and controlled study. Endoscopy. 2004;36:860–863. 20. Paspatis GA, Paraskeva K, Theodoropoulou A, et al. A prospective, randomized comparison of adrenaline injection in combination with detachable snare versus adrenaline injection alone in the prevention of postpolypectomy bleeding in large colonic polyps. Am J Gastroenterol. 2006;101:2805; quiz 2913.
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Use of Dual Knife for Large Pedunculated Colorectal Polyps Chia-Wei Yang, MD,* Hsu-Heng Yen, MD,*w Yang-Yuan Chen, MD,z and Maw-Soan Soon, MD*
Background: Endoscopic resection of large pedunculated colorectal polyps is technically difficult, especially when the polyps are so large that it is either not possible or too difficult to resect them using a conventional polypectomy snare.
be useful and safe.5 Here we describe our subsequent experience in the endoscopic management of large pedunculated colonic polyps using this novel technique and evaluate the safety, efficacy, complications, and limitations of this technique.
Aim: To facilitate the removal of pedunculated colorectal polyps, we developed a new technique using a combination of a dual knife and preventive hemostatic procedures. Methods: Nine patients (5 men and 4 women; mean age, 59.8 y; range, 49 to 79 y) with pedunculated polyps >2 cm in diameter were treated with this technique. A dual knife and endoclips or an endoloop were used as needed. Results: All lesions, except for 1 polyp, were resected endoscopically. The mean time for complete resection was 8.5 minutes (range, 1.5 to 16 min). The procedure time decreased significantly after the fifth case (168 vs. 746 s, P = 0.0009). No hemorrhage, perforation, or other complications occurred during follow-up among the endoscopically resected cases. Conclusions: Combined use of a dual knife and prophylactic hemostatic procedures is a feasible alternative technique for removing large pedunculated colorectal polyps when conventional snare resection is impossible or difficult. Key Words: endoscopy, colon, colon polyp, colon cancer, polypectomy, knife
(Surg Laparosc Endosc Percutan Tech 2014;24:444–447)
E
ndoscopic polypectomy is an established procedure for resecting colorectal polyps, which can also prevent colorectal cancer.1 The use of a conventional diathermic snare is limited for en bloc resection when the polyp diameter is nearly equal to or larger than the diameter of the snare. Piecemeal snaring of a large pedunculated colonic polyp is an alternative technique.2,3 However, this option may be unacceptable because of the increased risk of bleeding and the inability to conduct adequate pathologic examinations in cases of suspected malignancy.4 The removal of large or lumen-occupying pedunculated colonic polyps is a great challenge for endoscopists and the patient might require referral for surgical management. We previously reported our first experience with using a dual knife to remove 1 such lesion and found it to
Received for publication December 28, 2011; accepted September 20, 2012. From the *Department of Gastroenterology, Changhua Christian Hospital, Changhua; wSchool of Medicine, Chung-Shan Medical University, Taichung City; and zDepartment of Gastroenterology, China Medical University Hospital, Taichung City, Taiwan. The authors declare no conflicts of interest. Reprints: Hsu-Heng Yen, MD, Department of Gastroenterology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua 500, Taiwan (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
444 | www.surgical-laparoscopy.com
PATIENTS AND METHODS Patients A retrospective analysis of the endoscopy database identified 9 patients (5 men and 4 women; mean age, 59.8 y; range, 49 to 79 y) with 9 pedunculated colonic polyps over a 15-month period (July 2010 to November 2011) were included in this study. The diameters of their polyps were Z2 cm as measured using open biopsy forceps. These polyps were evaluated by both authors (H.-H. Y and C.-W. Y) who had experience with performing >500 colonoscopies per year for 5 years. They determined that a 1-step resection using a standard snare resection technique was not possible. Standard piecemeal resection or alternative dual knife–assisted resections were discussed with the patients before enrollment into this study. The study was carried out in accordance with the Helsinki Declaration. Written informed consent was obtained from all patients for the procedures that were performed. Patients receiving anticoagulant or antiplatelet therapy for cardiovascular diseases were instructed to discontinue the use of these drugs at least 5 days before the endoscopic procedure after consultations with a cardiologist and hematologist. Their medications were resumed if there were no signs of bleeding within 1 day of resection. Patients on hemodialysis were managed with heparin-free dialysis for 1 week before and after resection. All patients were evaluated for their coagulation profiles, including complete blood count, prothrombin time, and activated partial thromboplastin time.
Techniques and Equipment The cleansing of the bowel was performed by ingestion of a polyethylene glycol electrolyte lavage solution. After this, all patients received conscious sedation by administration of midazolam (2 to 5 mg) and meperidine (25 to 50 mg). To facilitate manipulation of the dual knife for colonic polyp resection, endoscopy was performed using a gastroscope (GIF-H260; Olympus, Tokyo, Japan) for a distal site of the colonic polyp or a colonscope (PCFQ260JL; Olympus) for a proximal site of the colonic polyp. To safely resect the polyp, prophylactic hemostatic procedures were applied before the resection, such as those using Endoclips (HX-600-135; Olympus) or a detachable Endoloop (MAJ-254; Olympus). If possible, we preferred using the endoloop over a polyp stalk with an estimated diameter of >1 cm because of its greater efficacy in achieving hemostasis and the technical difficulties involved in applying >2 hemoclips. The endoloop was placed and
Surg Laparosc Endosc Percutan Tech
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tightened until a cyanotic change in the polyp suggested adequate blockage of blood flow. For polyp resection, we used a Dual Knife (KD-650U; Olympus; Fig. 1) with an electrosurgical generator (endocut = 50 W; coagulation 30 W; effect 2; ICC = 200; ERBE Co., Tubingen, Germany). The knife length was 1.5 mm. The knife could be fixed in either an extended position for cutting the stalk above the ligation position by at least 3 mm under direct visualization or in a retracted position for coagulation when resection-related bleeding was encountered (Figs. 2–4). The procedure time recorded the interval between the passage of the Dual Knife through the working channel and stopped after complete resection of the polyp. The technique for using the dual knife for resecting the stalk, similar to using a needle knife, initially involves moving from the lateral side to the central area parallel to the bowel wall where the polyp is located. If needed, although not routinely recommended because of the risk of bowel wall injury behind the stalk, the knife can be pushed onto the stalk while carefully cutting from the proximal part forward to the distal part. This cutting forward maneuver should only be applied when a thick stalk is encountered, and should be performed more cautiously when using a needle knife because of the long knife tip (4 to 7 mm) of commercial devices compared with the Dual Knife [1.5 mm of model KD-650 Q/U used for esophageal and colorectal endoscopic submucosal dissection (ESD) and 2 mm of model KD-650 L used for gastric ESD]. This makes it difficult to control the knife accurately, especially in a narrow space. We use the dual knife in its retracted position with 0.3 mm of its needle tip exposed for coagulation to avoid excessive bowel wall injury. After resection, the polyp was captured using a basket catheter, and if possible, gently extracted through the anus or dragged to the rectum for spontaneous passage. We measured the absolute maximum diameter of the polyp head and stalk after its retrieval or spontaneous passage.
Histologic Examination Polyps were fixed in 10% formalin and then stained with hematoxylin and eosin for histopathologic assessment. Colorectal adenomas were histologically classified according to the World Health Organization Classification of
FIGURE 1. Dual knife: a 1.5 mm knife with a knob over its tip when in its extended position (left) and only 0.3 mm of its needle tip exposed in its retracted position (right). r
2014 Lippincott Williams & Wilkins
Endoscopic Resection for Large Polyps
FIGURE 2. A large pedunculated polyp in the descending colon (case 6).
Tumors.6 If cancer was detected, a decision for further aggressive surgical management was taken based on the level of cancer invasion. According to Haggitt classification,7 pedunculated polyps with carcinoma invading the head, neck, or stalk require no further treatment when the resection margins are free of cancer and there is no lymphatic or vascular invasion. Additional radical surgery was reserved for those polyps with carcinoma that had invaded into the submucosa of the bowel wall below the polyp stalk because of an increased risk of lymph node metastases.
Follow-up Evaluation If no complications occurred after the endoscopic procedure, the patients were discharged with a scheduled follow-up of at least 1 telephone contact within 3 days and a return to our outpatient services 1 week later. According to our institutional guideline, patients with malignant polyp without the need for surgery were scheduled for a follow-up colonoscopy 1 and 6 months later. For patients with
FIGURE 3. After applying 1 endoloop, the polyp became cyanotic above the level of ligation, thus ensuring sufficient tightening.
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decreased significantly after the fifth case (first 4 resected cases vs. last resected cases: 746 vs. 168 s, P = 0.0009). All polyps were adenomas; 4 patients had carcinomas arising in tubulovillous adenomas. These carcinomas were confined to the polyp head or stalk and their resection margins were free of cancer, thereby not requiring any further surgery. All patients who received complete endoscopic management had no delayed hemorrhage, perforation, or other complications for at least 3 months. The results are summarized in Table 1.
DISCUSSION
FIGURE 4. Use of a dual knife for cutting the polyp stalk above the level of ligation under direct visualization.
adenomas >1 cm, a follow-up colonoscopy was scheduled 6 months later.
RESULTS The clinical outcomes of our 9 patients are summarized in Table 1. All 9 polyps were >2 cm in diameter; the largest was 4 cm in diameter. The stalk diameters were at least 0.8 cm, with a greatest width of 2.5 cm. The locations were most often over the sigmoid colon (5/9 polyps), and the others were in the splenic flexure, the descending colon, and the cecum. The mean time for complete resection after applying the endoloop or endoclips was 8.5 minutes (range, 1.5 to 16 min). Resection failed for 1 patient (case 4). This was due to insufficient tightening of the endoloop because of the limited space for observation in the splenic flexure owing to the large polyp and wide stalk. Active bleeding was observed after the first resection attempt, and this patient was referred for surgical resection. The procedure time
When faced with pedunculated colonic polyps that are difficult to resect by maneuvering a conventional diathermic snare because of an occluded lumen or a polyp head size larger than the snare, stalk resection using a specialized device is an alternative technique. To remove these lesions en bloc, reported resection techniques include using a needle knife,8–10 an insulated-tip diathermy knife,11 or a grasping-type scissors forceps.12 In this study; we report the use of a dual knife as an alternative technique to remove large pedunculated colorectal polyps. The dual knife, a recently developed instrument for ESD,13 resembles a short needle knife with a knob-shaped tip. The small knob-shaped tip is useful for marking and for hemostasis in its retracted position. This feature makes the needle less likely to slip during resection of floppy polyps in its extended position. This results in improved overall knife maneuverability compared with a standard needle knife. In addition, polyps with wide stalks take more time to be resected, and removal of a floppy pedunculated polyp is more technically demanding. A large polyp with a long stalk (our cases 2 and 3) may move relatively freely within the lumen, making it difficult to control the knife during resection. In this situation, using gravity by a position change or placing a transparent cap on the scope can help to control the position of the polyp stalk to facilitate polyp resection. With the increased experience, the procedure time was reduced from 746 to 168 seconds (P = 0.0009) after the fourth successful case. Therefore, our study suggested this new technique is feasible with a short learning curve. The main complication with conventional polypectomy is bleeding, ranging from 0.3% to 6.1% of cases,
TABLE 1. The Clinical Features and Outcomes of our Patients
Polyp Head /Stalk size Location (cm)
Case
Age/ Sex
Ligation Method
Procedure Time
Outcome/ Complication
1 2
58/M 79/F
S S
4.0/2.5 2.5/1.0
EC + EL EC
13 min 45 s 16 min
Success/no Success/no
3
60/F
S
2.1/0.9
EC
9 min 30 s
Success/no
4 5
59/M 49/F
SF S
3.8/2.2 2.5/2.0
EC + EL EL
NA 11 min
Failure/surgery Success/no
6 7 8 9
56/M 61/F 59/M 58/M
D S C S
2.8/1.2 2.2/0.8 2.8/1.0 3.5/1.2
EL EL EL EL
1 min 30 s 3 min 5 min 1 min 45 s
Success/no Success/no Success/no Success/no
Pathology Tubulovillous adenoma Adenocarcinoma from tubulovillous adenoma Adenocarcinoma from tubulovillous adenoma. Tubulovillous adenoma Adenocarcinoma from tubulovillous adenoma Tubular adenoma Tubulovillous adenoma Tubulovillous adenoma Adenocarcinoma from tubulovillous adenoma
C indicates cecum; D, descending colon; EC, endoclip; EL, endoloop; F, female; M, male; NA, not available; S, sigmoid colon; SF, splenic flexure.
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Surg Laparosc Endosc Percutan Tech
Volume 24, Number 5, October 2014
depending on the polyp size, its location, and whether it has a broad base or a wide stalk.14 Therefore, prophylactic hemostatic procedures are required to prevent postpolypectomy hemorrhage. Mechanical hemostatic devices, such as the endoloop15,16 and endoclips,8–10 have been introduced for preventing early or delayed postpolypectomy hemorrhage. The endoloop, measuring 5 3 cm when fully opened, is maneuvered around the tip of the polyp with limited expansible force because of its thin nylon composition. It may be a challenge to fully open the loop in case of limited space, because of the large polyp size or narrow colon lumen diameter, particularly in the left colon or other flexure locations. Of note, it should be cautioned that an adequate distance from the ligated loop should be maintained during cutting to avoid slippage of the loop, which would result in wound bleeding. In addition, it has been reported that transection can be achieved with a sufficiently tightened loop if the stalk diameter is 2 cm). For our failed case, based on the above concepts, we believe that placing an endoloop is a more reliable choice for a polyp with a wide stalk, despite the difficulty involved and the time consumed in maneuvering the endoloop to the stalk because of the large polyp head with a narrow space. It is important to carefully ensure sufficient endoloop tightening by observing the color of the polyp head, which should change to dark red after ligation, and if needed, place another endoloop. In addition, epinephrine injection into the stalk might be another choice to prevent postpolypectomy hemorrhage, if one cannot confidently confirm the efficacy of the former mechanical technique. In conclusion, based on our experience, combined use of a dual knife and an adequate prophylactic hemostatic procedure is a novel, feasible, and alternative technique to conventional endoscopic treatment. It offers en bloc polyp removal in cases where conventional snare resection is impossible or difficult. A future study comparing
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2014 Lippincott Williams & Wilkins
Endoscopic Resection for Large Polyps
conventional techniques with snare and the technique with Dual Knife is still required. REFERENCES 1. Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993;329:1977–1981. 2. Binmoeller KF, Bohnacker S, Seifert H, et al. Endoscopic snare excision of “giant” colorectal polyps. Gastrointest Endosc. 1996;43:183–188. 3. Stergiou N, Riphaus A, Lange P, et al. Endoscopic snare resection of large colonic polyps: how far can we go? Int J Colorectal Dis. 2003;18:131–135. 4. Kurzon RM, Ortega R, Rywlin AM. The significance of papillary features in polyps of the large intestine. Am J Clin Pathol. 1974;62:447–454. 5. Yang CW, Yen HH. Novel use of combined dual knife and endoloop for resection of a large pedunculated colon polyp. Endoscopy. 2011;43(suppl 2 UCTN):E192. 6. Li ZS, Li Q. The latest 2010 WHO classification of tumors of digestive system. Zhonghua Bing Li Xue Za Zhi. 2011;40: 351–354. 7. Haggitt RC, Glotzbach RE, Soffer EE, et al. Prognostic factors in colorectal carcinomas arising in adenomas: implications for lesions removed by endoscopic polypectomy. Gastroenterology. 1985;89:328–336. 8. Cipolletta L, Bianco MA, Rotondano G, et al. Endoclipassisted resection of large pedunculated colon polyps. Gastrointest Endosc. 1999;50:405–406. 9. Chen YY, Su WW, Soon MS, et al. Hemoclip-assisted polypectomy of large duodenal Brunner’s gland hamartoma. Dig Dis Sci. 2006;51:1670–1672. 10. Luigiano C, Ferrara F, Ghersi S, et al. Endoclip-assisted resection of large pedunculated colorectal polyps: technical aspects and outcome. Dig Dis Sci. 2010;55:1726–1731. 11. Akahoshi K, Kubokawa M, Fujimaru T, et al. Endoscopic resection of a large pedunculated colonic polyp using an insulated-tip diathermy knife. Endoscopy. 2005;37:405–406. 12. 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. 13. Yen HH, Yang CW, Su PY, et al. Use of hemostatic forceps as a preoperative rescue therapy for bleeding peptic ulcers. Surg Laparosc Endosc Percutan Tech. 2011;21:380–382. 14. Rosen L, Bub DS, Reed JF III, et al. Hemorrhage following colonoscopic polypectomy. Dis Colon Rectum. 1993;36:1126–1131. 15. Rey JF, Marek TA. Endo-loop in the prevention of the postpolypectomy bleeding: preliminary results. Gastrointest Endosc. 1997;46:387–389. 16. Katsinelos P, Kountouras J, Paroutoglou G, et al. Endoloopassisted polypectomy for large pedunculated colorectal polyps. Surg Endosc. 2006;20:1257–1261. 17. Shirai M, Nakamura T, Matsuura A, et al. Safer colonoscopic polypectomy with local submucosal injection of hypertonic salineepinephrine solution. Am J Gastroenterol. 1994;89:334–338. 18. Hsieh YH, Lin HJ, Tseng GY, et al. Is submucosal epinephrine injection necessary before polypectomy? A prospective, comparative study. Hepatogastroenterology. 2001;48:1379–1382. 19. Di Giorgio P, De Luca L, Calcagno G, et al. Detachable snare versus epinephrine injection in the prevention of postpolypectomy bleeding: a randomized and controlled study. Endoscopy. 2004;36:860–863. 20. Paspatis GA, Paraskeva K, Theodoropoulou A, et al. A prospective, randomized comparison of adrenaline injection in combination with detachable snare versus adrenaline injection alone in the prevention of postpolypectomy bleeding in large colonic polyps. Am J Gastroenterol. 2006;101:2805; quiz 2913.
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