CAP XTENDER, A NOVEL APPROACH TO MANAGING PSEUDOPOLYPS

INTRODUCTION AND CASE PRESENTATION
A 40-year-old patient with a family history of colorectal cancer presented to an outside facility with hematochezia. A colonoscopy revealed multiple pedunculated atypical polyps interspersed across the sigmoid colon with a narrow lumen due to dense diverticulosis. The patient was referred to us to manage these atypical polyps that showed normal mucosa on biopsy except for one biopsy sample with hyperplastic changes. The patient reported severe straining and symptoms suggestive of intermittent partial obstruction. During the colonoscopy, we found multiple large polyps with changes representative of chronic submucosal hemorrhages, diverticula with hemorrhagic changes, and inverted diverticula, likely suggestive of excessive straining. Given this, there was a concern that if these polyps were resected, this could lead to full-thickness colonic perforation. None of the polyps had a mucosal pattern to support adenomatous change. These findings posed a management challenge as these atypical polyps were resulting in hematochezia, likely leading points for intussusception in the background of the family history of colon cancer.

ENDOSCOPIC INTERVENTION AND RESULTS
We used a novel approach in which we applied a banding kit over a hard cap to create an approximately 2 cm cap depth to suction these lesions in this extended cap and then put a band at the base to safely sample the polyp. We coined the Cap Xtender for this modified device, as shown in image 1. This extended device posed a challenge to navigate through the tight angulated sigmoid with multiple diverticula; however, continuous irrigation and the clear view through the proximal transparent cap allowed us to accomplish the goal. Another challenge was to pull the entire polyp into the cap so that the band could be applied on the healthy mucosa (and not partially necrose off a diverticulum) as well as to slough off the entire pathologic tissue Image 2.

Extensive tissue sampling was performed above the band, and none of these lesions showed any evidence of adenoma on pathology. Interestingly, the classic appearance of lamina propria thickening and submucosal hemorrhages confirmed our hypothesis that excessive straining was resulting in high intra-abdominal pressure, inversion of diverticula with submucosal hemorrhages that were prolapsing and resulting in intermittent intussusception and hematochezia. During follow-up, the patient remained asymptomatic, no residual polyps were noted, and the hematochezia resolved.

CONCLUSION
CAP XTENDER is a novel approach to safely manage and sample the pseudopolyps in difficult segments of the GI tract.