Endoscopic submucosal dissection with scissor-type knife for pedunculated polyp with short and thick stalk.

A 60-year-old man presented with mild bloody stool. He had no other symptoms. The results of laboratory tests for anemia, inflammation, and coagulation were normal. Colonoscopy revealed a polyp with a diameter of 4 cm in the distal sigmoid colon.

He was referred to our hospital for further evaluation. Colonoscopy showed that the polyp was morphologic type Paris-Ip; stalked polyp (Figs. 1A and B). Under narrow-band imaging (NBI), its surface showed a browner color than the surrounding normal mucosa, and its structure was composed of lighter areas surrounded by brown vessels; NBI International Colorectal Endoscopic (NICE) classification type 2 pattern (Fig. 1C). NBI partially showed more dysplastic area in the middle of the polyp head. There was no clear sign of submucosal invasion.

Figure 1

A, Endoscopic view of the basement part of the polyp showing short thick stalk. B, Endoscopic view of the head part of the polyp showing tubular and villous surface. C, Endoscopic view with narrow-band imaging (NBI) showing a tubulovillous surface pattern on the head of the polyp with no obvious invasive pattern. D, Endoscopic view of an ulcer after resection of the polyp. E, Endoscopic visualization of resected polyp; the specimen was 45 mm × 40 mm. F, Endoscopic view of ulcer after endoscopic submucosal dissection and complete closure by clips.

The pretreatment endoscopic diagnosis was tubulovillous adenoma with high-grade dysplasia. In a multidisciplinary conference, we decided to remove this polyp endoscopically and received informed consent from the patient. Because the stalk of the polyp was short and thick, thick vessels in the stalk were anticipated. Snaring could be risky for bleeding and also for incomplete en bloc resection. The stalk did not have enough space for presnaring looping.

Endoscopic submucosal dissection (ESD) with a commonly used needle-type knife could put the patient at risk for bleeding. We chose a scissor-type ESD knife (SBJr; Sumitomo Bakelite, Tokyo, Japan). In this situation, we thought we could maximize this knife’s advantage of precoagulation without endoscopic movement before cutting to avoid bleeding and for better manipulation. We used glycerol mixed with indigo carmine for injection, an attachment on the tip of the endoscope (Olympus, Tokyo, Japan), and an electric generator (ERBE Elektromedizin, Tubingen, Germany). The procedure was done in 45 minutes without adverse events, as shown in the video (Video 1, available online at www.VideoGIE.org). En bloc resection and R0 resection were achieved (Figs. 1D and E). The ulcer bed after resection was closed with clips (Fig. 1F).

The pathologic diagnosis was the same as the endoscopic diagnosis. No residual or recurrent polyp was found at a 6-month follow-up visit. A needle-type ESD knife is used often in colorectal ESD; however, for polyps with a short and thick stalk, as in the present case, a scissor-type ESD knife could be a good alternative.

Disclosure

All authors disclosed no financial relationships relevant to this publication.