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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).Endoscopic ampullectomy of a large neuroendocrine tumor using underwater EMR technique
Neuroendocrine tumors (NETs) arise from the enterochromaffin cells derived from the endoderm.1,2 GI NETs are a group of well-differentiated tumors, most commonly involving the appendix. NETs of the ampulla of Vater are extremely rare; thus, the natural history of these tumors is not clear. Rarely, they can have distant metastases.2-4 The standard of care has been complete surgical resection, such as pancreaticoduodenectomy or local surgical excision of the tumor, which has a high morbidity. Hence, endoscopic resection modalities such as endoscopic ampullectomy are increasingly being implemented.Endoscopic resection of large pedunculated colon polyps using only a scissor-type knife: a case series
All 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.Full-thickness resection of subepithelial nodules, allowing for the diagnosis of an unusual case of pneumatosis cystoides intestinalis
A 61-year-old otherwise healthy man was referred to us for further evaluation of multiple firm, large, subepithelial descending colonic nodules. The area of nodularity was found incidentally on a screening colonoscopy and was located in the descending colon near the splenic flexure. The nodules extended over a length of 5 cm and varied in size from 1 cm to 2.5 cm. One nodule was sampled several times; however, examination of biopsy specimens revealed only colonic mucosa with inflammation and architectural distortion.Suction marking method: a novel technique to prevent overlooking of polyps detected upon endoscope insertion
It has been established that removal of adenomas reduces the prevalence and mortality of colorectal cancers.1,2 Because the miss rate of polyps in colonoscopy remains high, an appropriate approach for all polyps, even for lesions detected upon endoscope insertion, plays an important role in achieving high-quality colonoscopy.Transient hypotension during endoscopic resection of gangliocytic paraganglioma with ampullary involvement
Gangliocytic paraganglioma (GP), biologically similar to pheochromocytoma, is a rare tumor predominant in the second portion of the duodenum.1 GP is histologically composed of 3 types of cells: epithelioid endocrine cells, ganglion-like cells, and spindle-shaped cells.2 Although EUS-guided FNA is useful for preoperative diagnosis, small biopsy specimens make diagnosis difficult. In some cases, surgery has been performed for diagnosis. Here, we report a case in which endoscopic papillectomy (EP) was used as a diagnostic modality.Treatment of neoplastic colonic lesions using the full-thickness resection device
Advanced adenomas and scarred lesions pose difficulties for the endoscopist because of the need for complete resection and accurate pathologic staging, which cannot be afforded by standard resection techniques. Endoscopic full-thickness resection, first described in Europe for treatment of early adenocarcinoma or scarred lesions in the colon, allows potentially curative en bloc resection in patients who may be at a high risk for surgery. We describe our endoscopic approach and histologic outcomes with use of a commercially available endoscopic full-thickness resection device (FTRD) (Ovesco Endoscopy, Tubingen, Germany).Endoscopic submucosal dissection of esophageal metastatic melanoma
A 65-year-old man underwent surgical excision with lymph node dissection for a scalp melanoma in 2011. In 2018, he presented to his melanoma oncologist for routine follow-up and subsequently underwent an upper endoscopy for reflux symptoms. His upper endoscopy revealed a pigmented lesion in the esophagus, biopsy specimens that showed malignant melanoma. Positron emission tomography/CT and magnetic resonance imaging of the brain revealed no evidence of distant metastases. He was referred for further endoscopic evaluation and treatment.Management of arterial bleeding after endoscopic resection of a neuroendocrine gastric tumor
We report a case focusing on the management of arterial bleeding after endoscopic resection of a neuroendocrine gastric tumor (NET) (Video 1, available online at www.VideoGIE.org ).Endoscopic resection of a giant fibrovascular esophageal polyp by use of a scissor-type knife
A 73-year-old woman presented to the emergency department because of loss of consciousness; she recovered within a few minutes. Chest CT revealed a large intraluminal tumor arising from the proximal esophagus (Fig. 1). Accordingly, she was referred to our department. Barium esophagography revealed an approximately 10-cm-long intraluminal esophageal mass arising from the cervical esophagus (Fig. 2).Duodenal endoscopic submucosal dissection for a large protruded lesion located just behind the pyloric ring with a scissor-type knife
Recently, endoscopic submucosal dissection (ESD) has been applied to the treatment of GI lesions to enable en bloc curative resection.1,2 Generally, large tumor size, protruded lesion, poor endoscope maneuverability, and other procedural factors may contribute to the technical difficulties of ESD and periprocedural perforation.3,4 Among ESD procedures for GI lesions, duodenal ESD is the most technically challenging procedure because of the thin wall and narrow lumen of the duodenum, as well as poor maneuverability of the endoscope in the duodenum.Endoscopic resection of a gigantic gastric polyp causing symptomatic iron-deficiency anemia
A 69-year-old man with a history of carotid artery stenosis who was taking clopidogrel presented with dyspnea secondary to acute iron-deficiency anemia. His hemoglobin level was 6 g/dL. He underwent EGD at an outside center, which revealed a large bleeding gastric polypoid lesion. Histopathologic examination of a biopsy specimen revealed a hyperplastic polyp with superficial erosions but no dysplasia. He underwent 3 attempts at endoscopic resection over the next several months at the outside center, which were all unsuccessful.Endoscopic resection of an unusual ampullary adenoma
A 40-year-old woman with no comorbidities presented with episodic postprandial bilious vomiting of 6 months’ duration and mild abdominal discomfort. Her liver function tests showed normal bilirubin with raised alkaline phosphatase and γ-glutamyltransferase. Abdominal US had shown dilatation of the common bile duct (CBD) and pancreatic duct (PD). She had previously undergone MRCP, which showed diffuse dilatation of the CBD, common hepatic duct, and intrahepatic biliary radicles with smooth tapering at the region of the ampulla, diffuse prominence of the main PD, and ectopic ampulla of Vater.Endoscopic transcecal appendectomy: a novel option for the treatment of appendiceal polyps
Although most polyps involving the appendiceal orifice can be removed endoscopically,1 removal of polyps originating inside the appendix is currently feasible only by surgical appendectomy.2 We have previously reported endoscopic transcecal appendectomy for appendiceal cysts.3 In this case, we investigated the feasibility and safety of endoscopic transcecal appendectomy for the treatment of appendiceal polyps originating inside the appendix.Usefulness and safety of colorectal precutting EMR and hybrid endoscopic submucosal dissection for sessile serrated polyps with use of a novel multifunctional snare
Precutting EMR (defined as a technique in which snaring is done without dissecting the submucosal layer after the circumference of the lesion alone is incised by using a knife or the tip of a snare) and hybrid endoscopic submucosal dissection (ESD) (defined as a technique in which the submucosal layer is dissected and snaring is carried out after the ESD procedure by use of a knife for ESD or the tip of a snare) have the advantages of decreased procedure time and decreased perforation risk over conventional ESD.Bite-on-bite technique for removal of a gastric subepithelial lipoma
A 55-year-old man with no relevant medical history underwent EGD for the evaluation of dysphagia. A submucosal nodule was found in the gastric antrum, and he was referred to our center for further evaluation and treatment. EGD at our facility found a 1-cm subepithelial lesion in the gastric antrum (Fig. 1). The mucosa overlying the lesion appeared normal, with a "yellowish" hue; the remainder of the stomach and duodenum appeared normal.Endoscopic en bloc removal of appendiceal polyp facilitated by traction
Colonoscopy is widely used for the removal of colonic polyps to prevent the future development of colorectal cancer.1-3 However, incomplete resection of these precancerous colonic polyps often results in recurrent polyps4,5 and is also strongly associated (odds ratio, 4.76) with interval development of the colorectal cancer after previous colonoscopy.6Tissue retractor system–assisted endoscopic submucosal dissection of a large rectal tumor with significant fibrosis from direct tattooing
Endoscopic tattooing directly into large dysplastic lesions is often performed for lesion identification before EMR or endoscopic submucosal dissection (ESD). Several case reports have demonstrated the difficulty of attempting endoscopic resection of previously tattooed lesions, primarily because of tattoo-induced submucosal fibrosis, inadequate lifting of the lesion, and obscuring of the dissection planes.1-3Simultaneous detection and characterization of diminutive polyps with the use of artificial intelligence during colonoscopy
The application of artificial intelligence (AI) in colonoscopy is attracting a growing amount of attention because it has the potential to improve the quality of colonoscopy.1,2 The main focuses of research in this field comprise automated polyp detection3,4 and characterization5,6 (ie, pathologic prediction), which may respectively contribute to a higher rate of adenoma detection and a reduction of the costs related to unnecessary polypectomy. However, there has not yet been any report of technology capable of simultaneous polyp detection and characterization, which is the optimal situation for fully automated colonoscopic observation.Precutting EMR with full or partial circumferential incision with a snare tip for the en bloc resection of difficult colorectal lesions
EMR is performed worldwide as a standard therapy for colorectal polyps. It is difficult to achieve en bloc resection by EMR for a colorectal tumor ≥20 mm; the en bloc resection rate for tumors ≥20 mm is reported to be only approximately 30%.1 Additionally, inappropriate elevation resulting from fibrosis and problematic locations can make EMR difficult, even for tumors <20 mm.Pulley traction-assisted colonic endoscopic submucosal dissection affords good visibility of submucosal layer
A 75-year-old man underwent surveillance colonoscopy after polypectomy at another institution. Colonoscopy revealed a laterally spreading tumor involving a diverticulum in the ascending colon. He was referred to our hospital for further examination and treatment.Duodenal endoscopic submucosal dissection and sutured defect closure across a lumen-apposing metal stent
Patients with gastric bypass anatomy face unique challenges and limited options with respect to endoscopy in the bypassed portion of the stomach and duodenum.1 Here we introduce a novel technique for EUS-guided creation of a temporary access tract and demonstrate various therapeutic interventions that can be safely and effectively performed across the access tract in the bypassed duodenum (Video 1, available online at www.VideoGIE.org ).Clip-assisted EMR: a new resection technique for treating flat remnants of colonic polyp tissue during piecemeal EMR
Piecemeal EMR is the preferred endoscopic treatment of large sessile colonic polyps. Although the procedure is safe and effective, local recurrence rates after EMR are high, ranging from 10% to 30% in various reports, especially after piecemeal resections.Endoscopic resection of a giant solitary fibrous tumor of the esophagus
A 63-year-old woman with a medical history of hypertension, hypothyroidism, and GERD presented to our clinic with worsening dysphagia to solids. EGD performed by a local gastroenterologist showed a large esophageal mass. CT of the chest with contrast material revealed a high-density, nearly occlusive, esophageal mass, beginning at the thoracic inlet, measuring 3.8 cm × 2.1 cm × 10.4 cm (transverse, anteroposterior, craniocaudal), and demonstrating well-delineated smooth margins without esophageal disruption (Fig. 1).Modified over-the-scope clip with telescope endoscopic full-thickness resection for colonic adenoma involving diverticulum
An 82-year-old man who underwent colonoscopy for iron-deficiency anemia was found to have a 15-mm polyp (Paris 0-IIa, type II NICE classification) involving the entire circumferential of the diverticulum in the distal descending colon. Biopsy specimens from this polyp revealed tubular adenoma with high-grade dysplasia. He was referred for endoscopic resection of this polyp (Video 1, available online at www.VideoGIE.org ).Successful 2-channel cold snare polypectomy of a colorectal lesion involving the appendiceal orifice
Colonic polypectomy is a common procedure with several approaches to remove small polyps.1 However, there is no established endoscopic treatment for lesions on the appendiceal orifice that cannot be wholly observed; surgery is recommended for such lesions when endoscopic treatment is not feasible.2Sigmoid colon polyp EMR with novel endoscopic morcellator
A 65-year-old woman underwent screening colonoscopy and was found to have a 60-mm polyp that was removed in piecemeal fashion by another gastroenterologist. The initial pathologic examination noted tubular adenoma with high-grade dysplasia. Repeated surveillance colonoscopy 3 months later noted a 20-mm area of residual focus that was draping over a fold. Examination of repeated biopsy specimens taken at that time noted tubular adenoma without high-grade dysplasia or malignancy (Fig. 1A). Owing to risk factors, such as prior high-grade dysplasia and the location and characteristics of the polyp, the patient was referred to a colorectal surgeon for evaluation.Underwater EMR with submucosal lift for a small intestinal polyp in a patient with Peutz-Jeghers syndrome
Underwater EMR is considered an alternative technique to standard polypectomy in the management of difficult cases. This method has been reported to be effective for treatment of duodenal and colonic polyps. However, the efficacy and safety of underwater EMR for small intestinal polyps are still unknown.Cold snare polypectomy for polyp adjacent to colonic diverticulum
Colonic diverticula are caused by increased intracolonic pressure or by a weakened colonic wall. Most colonic diverticula consist of acquired pseudodiverticula and do not have a muscle layer. Therefore, there is a risk for perforation when EMR is used for polyps adjacent to diverticula. We report 2 cases of cold snare polypectomy for polyp adjacent to colonic diverticula (Video 1, available online at www.VideoGIE.org ).Closure of large colonic defects by use of submucosal buttressed clips
Clip closure of large defects after endoscopic resection is often performed to prevent or treat bleeding and perforation. Clip closure may be difficult in the colon because the mucosa is slippery and weak.EMR of large laterally spreading lesion of the duodenum involving the ampulla
A 70-year-old woman was referred to our hospital for management of a large, nearly circumferential, laterally spreading lesion (LSL) of the duodenum involving the ampulla of Vater (Fig. 1A), which was incidentally diagnosed during endoscopic investigation of diarrhea. Her medical history included severe chronic obstructive pulmonary disease; rheumatoid arthritis, for which immunosuppressive medication was prescribed; and heterozygote factor V Leiden requiring anticoagulant therapy. Because of the ampulla involvement, magnetic resonance cholangiopancreatography was performed and showed absence of adenoma intraductal extension and absence of pancreas divisum.Usefulness and safety of a scissors-type knife in endoscopic submucosal dissection for nonampullary duodenal epithelial tumors
Duodenal endoscopic submucosal dissection (ESD) is considered challenging because of poor endoscopic operability. Furthermore, the muscle layer of the duodenum is thinner than that of any other site in the GI tract, resulting in higher reported perforation rates of up to 30%.1-3 To prevent the risk of adverse events (especially perforations) associated with the use of a conventional knife in ESD for nonampullary duodenal epithelial tumors (NADETs), we used a scissors-type knife, a stag beetle (SB) Knife Jr (Sumitomo Bakelite Co, Tokyo, Japan), which maintains an adequate dissection layer and a controlled cut that prevents unexpected muscular layer injuries.Short cap technique to complete EMR of very flat colorectal laterally spreading tumors
We demonstrate the utility of a short cap placed over the colonoscope tip to facilitate EMR of very flat portions of laterally spreading tumors (LSTs) (Fig. 1A). Snare resection is preferred over ablative techniques for the removal of very flat portions that resist snaring. Snaring of very flat portions is often frustrating because even a stiff snare may slide over the very flat tissue.Endoscopic recognition of the sessile serrated polyp to cancer sequence
Sessile serrated polyps (SSPs), also called sessile serrated adenomas (SSAs), are the precursor lesions of 20% to 30% of colorectal cancers. The serrated polyp to cancer sequence occurs primarily in the proximal colon in the case of SSPs.Rectal polyp reaching the dentate line: underwater EMR without submucosal lift
A rectal polyp reaching the dentate line (RPDL) is challenging to resect. Traditionally, such polyps are referred for surgery, and patients are offered either major abdominoperineal resection (with a high rate of adverse events) or minimally invasive transanal endoscopic microsurgery (TEMS). Endoscopic submucosal dissection can also be technically challenging, with a steep learning curve and rates of adverse events of 2% for bleeding, 4% for perforation, and 4% for recurrence.1 EMR of an RPDL is technically difficult, although it results in fewer adverse events than does TEMS, but it has a higher recurrence rate (32% vs 10%).A rare case of giant fibrovascular polyp endoscopically resected with loop and cut technique
Giant fibrovascular polyps (GFVPs) of the esophagus are a rare condition arising from the hypopharynx or from the cervical esophagus. They are generally benign, and malignant transformation is uncommon.1 The majority of GFVPs are diagnosed in men between 60 and 70 years of age and are larger than 5 cm.2,3 The most common symptoms are dysphagia, respiratory symptoms, and regurgitation of polyps.4 More rare are bleeding, odynophagia, and cough.5Needle-knife polypectomy in the duodenum assisted by peristaltic tension
A 46-year-old woman was referred for investigation of iron-deficiency anemia. History, examination, and laboratory investigation did not establish the cause. Fecal immunohistochemical testing was positive, and endoscopic evaluation was recommended (Video 1). EGD revealed a 0-1p polyp arising from the inferolateral wall of the second portion of the duodenum (Figs. 1A and B). Snaring the lesion proved impossible despite repositioning attempts. Hemostasis clips were applied prophylactically to the polyp stalk (Figs. 1C and D).
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