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Create a Free AccountProcedures - Polypectomy
The interventional direct peroral cholangioscopy toolbox for endoscopic snare resection of a high-grade biliary intraductal neoplasia
Direct peroral cholangioscopy (DPOC) is a valuable diagnostic and therapeutic tool for various biliary disorders because it allows direct endoscopic visualization of biliary lumen and mucosal abnormalities. Direct cholangioscopy carries several benefits, including high-definition imaging with the availability of narrow-band imaging, lower operating expenses and cost, and the ability to use a wide range of accessories through the working channel.1,2 In this article, we demonstrate endoscopic techniques for performing biliary intraductal polypectomy using the ultra-slim pediatric gastroscope (GIF-H190N; Olympus America, Center Valley, Pa) and showcase the various endoscopic accessories available for use.Endoscopic full-thickness resection of gastric ulceration with persistent low-grade dysplasia using full-thickness resection device
Endoscopic mucosal resection and endoscopic submucosal dissection (ESD) are well-established treatment methods for resection of precancerous gastric lesions and early gastric cancers.1 Ulcerated or scarred gastric lesions are challenging to resect with EMR or ESD because of submucosal fibrosis and scarring, and hence, carry increased risk for perforation.2Hybrid endoscopic submucosal dissection for anal canal fibroma
An 83-year-old bedridden woman was referred for a suspected rectal polyp that frequently protruded from the anus when passing stools. Although the mass would reduce spontaneously, she experienced extreme discomfort, tenesmus, and occasional rectal bleeding. Ambulatory proctoscopy at the surgery department suggested a tumor in the lower rectum or anal canal.Wide-field endoscopic mucosal resection of laterally spreading rectal tumors using a multiband ligation endoscopic mucosal resection technique
Advanced tissue resection techniques such as EMR and endoscopic submucosal dissection (ESD) have been established as therapeutic options for the management of advanced mucosal neoplasia of the colon. EMR has been found to safely and effectively remove sessile or flat neoplasms confined to the superficial layers of the GI tract.1Successful endoscopic submucosal dissection for a tumor located completely within a colonic diverticulum after inversion of the diverticulum using a traction device
A 59-year-old man was diagnosed as having a flat-elevated tumor measuring 10 mm in diameter in the colon; the tumor was completely located within a colonic diverticulum in the hepatic flexure (Fig. 1A to C). Based on endoscopic evaluation, we determined there was a good chance of obtaining curative resection by endoscopic means. In addition, because we made it possible to invert the diverticulum into the colonic lumen by traction with forceps, we scheduled endoscopic submucosal dissection (ESD) using a traction device with the patient under general anesthesia (Fig. 1D).Prophylactic appendiceal retrograde intraluminal stent placement (PARIS)
EMR or endoscopic submucosal dissection (ESD) are highly effective methods for resecting colonic polyps1-4 but are ineffective when removing polyps arising from the appendiceal orifice. Endoscopic full-thickness resection (EFTR) using the full-thickness resection device (FTRD; Ovesco, Tuebingen, Germany) is a favorable approach for the management of such lesions because it overcomes the potential risk of perforation or incomplete resection by deployment of an over-the-scope clip (OTSC) beneath the polyp before resection.How to trick artificial intelligence: rectal heterotopic gastric lateral spreading tumor
We present the case of a 54-year-old man who came to our attention in January 2020 for a follow-up colonoscopy. He was treated in 2006 with a right hemicolectomy for an adenocarcinoma of the ascending colon. All consecutive follow-up colonoscopies had negative findings until 2016.Endoscopic resection of large Paris 0-Ip pedunculated polyps: video demonstration of recent U.S. Multi-Society Task Force recommendations on resection and removal for general endoscopists
Large pedunculated polyps have several unique features that contribute to the complexity of their removal. Pedunculated polyps typically have larger feeding blood vessels in their stalk, which increases the risk of immediate and delayed postpolypectomy bleeding. In addition, maneuvering instruments around the head of very large polyps can be difficult within the confined space of the colon lumen. The 2020 U.S. Multi-Society Task Force Recommendations on the Endoscopic Removal of Colorectal Lesions have offered best practice recommendations on the resection and removal of pedunculated lesions.Endoscopic submucosal dissection using scissors-type knife for a giant solitary duodenal polyp
Resection of giant pedunculated duodenal polyps is challenging. En bloc resection is preferred because of the risk of invasive cancer. EMR carries a significant risk of bleeding and perforation and may not be feasible when polyps are large. Traditional endoscopic submucosal dissection (ESD) carries a significant risk of perforation owing to the thin muscular layer of the duodenal wall and poor endoscopic operability. A scissors-type ESD knife has been increasingly used for resection of polyps in the stomach, duodenum, and colon.Emerging therapies in translational endoscopy: new frontiers in endoscopic submucosal dissection
The field of therapeutic endoscopy is evolving with a variety of new endoscopic surgical procedures. One such procedure, endoscopic submucosal dissection (ESD), has proven efficacy, yielding high margin-negative (R0) resection rates with low rates of adverse events and recurrence.1 However, the technical complexity, long procedure duration, and steep learning curve associated with ESD have led to relatively slow adoption. Although there has been an increased trend in devices and tools that may assist with ESD, there remains a paucity of advances in endoscopic technology, which are much needed given these known barriers.Endoscopic transcecal appendectomy under laparoscopic single-port assistance
A 72-year-old man was detected as having a flat-elevated tumor located in the appendix, measuring 15 mm in diameter (Fig. 1A). The lesion completely covered the appendiceal orifice, and the edge of the lesion could not be visualized (Fig. 1B). Because patients usually want minimally invasive treatments, endoscopic transcecal appendectomy was scheduled after the patient provided informed consent. It is our strategy to use a single port to introduce the laparoscope and confirm the condition around the appendix, to guide the endoscope safely, and to endoscopically resect the lesion and close the defect.Successful endoscopic management of adult ileocecal intussusception secondary to a large ileal lipoma
A 90-year-old man presented to our hospital with abdominal pain, nausea, and loss of appetite that started the day before arrival. Initial CT revealed a target sign with a low-density mass at the center located in the terminal ileum (Fig. 1). Although a severely distended small bowel and ascites were present, physical and serum laboratory findings were not suggestive of peritonitis. From the CT findings, the patient was diagnosed with adult intussusception secondary to a lipoma. Because vital signs were stable and abdominal pain was under control without administration of anesthetics, we attempted endoscopic reduction under fluoroscopic guidance (Video 1, available online at www.VideoGIE.org ).Over-the-scope-clip treatment for perforation of the duodenum after endoscopic papillectomy
Endoscopic papillectomy is an alternative to surgery for tumors of the ampulla of Vater. Adverse effects of the procedure, however, include pancreatitis, bleeding, and papillary stenosis, as well as occasional perforations,1 which are sometimes challenging to treat endoscopically. A novel endoscopic closure device, the Over-the-Scope Clip (OTSC; Ovesco Endoscopy, Tübingen, Germany) System, has increased the ability of the therapeutic endoscopist to close gastrointestinal luminal defects and treat gastrointestinal bleeding.Band ligation-assisted endoscopic mucosal resection of an intradiverticular polyp
With over 140,000 new colorectal cancer cases anticipated in 2020 by the American Cancer Society, colonoscopy remains a standard of care in the screening and further evaluation of precancerous colorectal lesions.1 Although a trained gastroenterologist is able to routinely perform screening colonoscopies as part of daily practice, the location of some polypoid lesions might pose a challenge.Endoscopic management of a type III choledochal cyst (choledochocele) using snare resection without balloon-catheter assistance
A 19-year-old man with acute recurrent pancreatitis was referred to our institution. He presented with typical upper abdominal pain and hyperamylasemia. Laboratory testing showed that blood amylase was 845.74 U/L and urine amylase was 6438.7 U/L. A liver function test showed that alanine aminotransferase was 62.9U/L, aspartate aminotransferase was 86.5U/L, total bilirubin was 45 umol/L, and direct bilirubin was 20.8 umol/L. He had normal lipid, and no history of alcohol consumption and trauma.Cold snare endoscopic mucosal resection for the removal of large nonpedunculated colon polyps
For large, >1-cm, nonpedunculated colon polyps, resection has historically been performed by using an electrocautery-based (hot) snare.1 Previous studies, including a large recent systematic review and pooled analysis, suggest that cold-snare EMR is safer than hot-snare EMR.2 Data have shown a decreased risk of adverse events such as delayed bleeding, postpolypectomy syndrome, and perforation when using cold-snare EMR compared with hot-snare EMR. In addition, cold-snare EMR has been shown to be at least as effective as conventional electrocautery-based resection with regard to complete resection and recurrence rates.Use of a new traction device to expose the base of a pedunculated appendiceal polyp
Endoscopic treatment of an appendiceal lesion has been considered challenging because of the great difficulty in attempting endoscopic insertion into the appendix. The risk of perforation and bleeding increases when endoscopic treatment is performed without a complete picture of the lesion. We report a case in which the S-O clip (TC1H05, Zeon Medical, Tokyo, Japan) was very useful in the endoscopic treatment of an appendiceal polyp.Peroral endoscopic myotomy with diverticulum resection
For esophageal diverticula with symptoms, thoracoscopic or laparoscopic surgery is usually performed. Epiphrenic diverticulum is often acquired because of the pressure caused by esophageal motility disorders.1 We devised a method of endoscopic esophageal diverticulum resection by applying the peroral endoscopic myotomy (POEM)2 and POEM + fundoplication3 technique, thus enabling a safer and less-invasive treatment that was equivalent to surgical treatments.Use of a rigidizing overtube to complete an incomplete colonoscopy
The successful completion of colonoscopy can be limited by endoscopist skill, bowel preparation, and looping.1 A variety of different techniques are available to manage looping, such as abdominal splinting, use of variable-stiffness colonoscopes, and reduction maneuvers.1-3 If cecal intubation remains difficult despite these maneuvers, overtube-assisted colonoscopy may help achieve this goal. This may include the use of single-balloon or double-balloon enteroscopy, spiral enteroscopy, or colonic overtubes.Cold snare polypectomy in combination with a traction device for resection of a colonic adenoma partially extending into a diverticulum
Colonic diverticula lack a muscular layer because they typically develop as a result of the herniation of mucosa and submucosa through a muscle layer that the vasa recta penetrates. The herniation is caused by increased intraluminal pressure. Endoscopic resection of tumors near colonic diverticula is difficult and dangerous because of the aforementioned anatomic features. Endoscopic resection–related adverse events have been reported.1Detachable snare to prevent postpolypectomy bleeding
Pedunculated polyps with a thick stalk (>5 mm) have an increased risk of bleeding with resection.1 Bleeding risk can be reduced by placing a detachable snare around the stalk of the polyp before resection.2-5 In this video (Video 1, available online at www.VideoGIE.org ), we demonstrate step-by-step use of a detachable snare for resection of a large pedunculated gastric polyp. The indications for use of a detachable snare include prevention or treatment of postpolypectomy bleeding, particularly of pedunculated polyps with a thick stalk or gastric polyps.Endoscopic full-thickness resection of a stomach gastrointestinal stromal tumor using a dedicated full-thickness resection device
Endoscopic full-thickness resection (EFTR) is increasingly performed for the removal of GI subepithelial lesions (SELs). EFTR is minimally invasive compared with surgery but still can procure an adequate specimen for histologic assessment. A dedicated EFTR device (Ovesco Endoscopy, Tübingen, Germany) has been developed for the management of colorectal lesions.1 Data on its safety and efficacy for lesions in the upper GI tract are limited.2,3 In this case, we share our experience with the off-label use of a dedicated EFTR device for the removal of a GI stromal tumor (GIST) in the stomach.Delineating sessile serrated adenomas/polyps with acetic acid spray for a more accurate piecemeal cold snare polypectomy
Cold snare polypectomy (CSP) is becoming one of the therapeutic methods of choice for benign polyps in light of its time- and cost-effective properties compared with hot snare polypectomy.1 The safety and effectiveness of piecemeal CSP (pCSP) of large sessile serrated lesions (SSLs) have been studied in the past,2,3 and we have reported pCSP for SSLs without using injection.4 The method was effective, but minor bleeding around the edge of the SSL often rendered examination for remnant tumors more difficult.Endoscopic resection of a duodenal Brunner gland hamartoma presenting with GI bleeding
A 64-year-old man with a history of diabetes mellitus, hypertension, chronic kidney disease, and primary mycotic infrarenal aortitis complicated with pseudoaneurysm formation after repair was seen at our hospital with a 3-day history of weakness and melena. His hemoglobin level on presentation was 6.1 g/dL from a baseline of 12.5 to 13 g/dL. International normalized ratio and platelet count were normal. Upper EGD was performed and revealed a large submucosal duodenal mass arising from the distal bulb to the second portion of the duodenum without involving the ampulla.A simple and cost-effective method: piecemeal cold snare polypectomy without injection for a large sessile serrated lesion ≥20 mm
Cold snare polypectomy (CSP) has become a common treatment for small polyps, but a size limitation exists because some lesions are insufficient for precise histologic examinations. If the lesion measures 10 mm or more, its possibility of having malignant potential increases1; this is the reason why the limitation exists for CSP.2 Although sessile serrated lesions (SSLs) are important precursors of colorectal cancer, it is not known whether treatment is safer and more effective particularly for large SSLs (≥10 mm).
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