BACKGROUND
Managing giant pedunculated gastrointestinal polyps (>5cm) is challenging due to hemorrhage from a retracted feeding artery and the inability to debulk if the polyp is cut in toto. A detachable snare (endo-loop) is a valuable tool to cinch pedunculated polyp. Its opening size and complex maneuvering limit it, and it usually gets caught in the soft polyp tissue. We describe a novel approach to resect the difficult pedunculated polyps.

CASE PRESENTATION
A 60-year-old Female was noted to have an incidental 6 cm polyp with a 3 cm stalk during MRI. Biopsy revealed an adenoma with low-grade dysplasia. As the patient was hoping to avoid surgical resection, we proceeded with EGD to evaluate the possible resection. Various attempts were unsuccessful to cinch this pedunculated polyp, including a standard detachable snare, dual scope to manipulate the detachable snare, and endoscopic purse-string suturing (IMAGE 1).

PREPARATION OF NOVEL SNARE AND ENDOSCOPIC INTERVENTION
A novel large-diameter detachable snare with a knot was created. A double-channel scope was preloaded with the novel detachable snare, and the knot was held with pin-less biopsy forceps to help steer the detachable snare (Image 2). With this approach, we successfully cinched the peduncle of the polyp. The polyp was debunked till we reached the peduncle. Given the smaller size, we could then place the standard detachable snare and successfully retrieved the peduncle separately so that the involvement of the peduncle could be assessed.

CONCLUSION:
We demonstrate the successful use of customized large-diameter detachable snare steered with pin-less forceps to safely and successfully remove a giant pedunculated gastric polyp

Image 1: Failed standard detachable snare, dual scope manipulation and endoscopic purse string suturing

Image 2: Novel detachable snare assembly and pin-less forceps to steer were preloaded in a double-channel scope

Anil Harrison

Appearances