by Klaus Mönkemüller, MD, PhD, FASGE, FJGES
Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA
Traditionally difficult polyps have been defined by their shape (e.g. larger than 20 mm, flat, thick stalk) or location (cecum, angulated part of colon, close to appendix orifice or diverticulum). However, we believe that other “situation” factors such as colon preparation, colon motility (e.g. spams, patient respirations), bleeding diathesis (e.g. anticoagulation, low platelets) and ergonomics (e.. video monitor on endoscopy cart instead of being in the wall in front of the endoscopists) contribute to the difficulty in resecting these lesions (1, 2). Here we describe various tricks that will assist you tackling and mastering many of these challenging factors during polypectomy.
Figure 1. Top tricks to deal with difficult polyps
This broad-based, thick stalked polyp was located in a difficult location, at a tight corner in the distal sigmoid colon (1A).
Essential steps:
-
Clean the colon (1B). A clean working field facilitates work. We like to instill water proximally to the lesion, as it is preferably to receive a “clean water gush” during resection as being gushed with debris (stool) laden material. In addition, in case of perforation, there is less stool contamination
-
Straighten the colonoscope to allow for “one-on-one” steering. You should be able to obtain the responses you want from the tip of the scope when torqueing it to the right and left.
-
Characterize the lesion and determine its endoscopic resectability (1C, 1D).
-
Place the polyp at the 5 to 7 o´clock position (1E). This will allow you to use the utensils properly, as they exit the working channel of the scope, which is on the lower parts of the scope (see No. 5).
-
It’s imperative to place your working channel in a way that the utensil travel to the base of the lesion (1F). Here you see the needle inserted into the thick stalk.
-
Create a generous submucosal cushion (see the videos about “How to Create a Submucosal Cushion” on Endocollab.com). Our motto is “big enough to allow good catch of the lesion with subsequent perfect R0, but not too big that the cushion displaces the polyp”. In essence, creating a submucosal cushion is sort of an “art” that requires great coordination with your assistant. The concept about “four quadrant” injections to create a cushion is a myth. Indeed, in this case you can see that just one well-placed injection sufficed to create a wonderful submucosal cushion. We always use “dynamic injection technique” (See Video on EndoCollab.com). The dynamic injection technique consist of two parts: a) the assistant pushes the syringe intermittently, like a “pump”, and you can observe how a cushion is creating by “dynamic pulsations”. This technique ensures a more controlled injection. And, b) we move the tip of the scope or inserted needle “dynamical”, either right or left or up or down movement. This depends on the location of the polyp. This movements ensure a nice distribution of the injected substance into the submucosa.
-
When advancing the snare it is always practical to slowly open it proximal to the polyp. In this case I placed the snare on the right side (Figure 1G, Figure 2A). When the tip of the snare was slowly opened by the assistant (Figure 2A, green arrow) we torqued the scope to the right (Figure 2B). This combined (snare-opening, scope torqueing) maneuver allowed for the snare to open like an “arch” (Figure 2B, yellow arrow), as its tip was touching the opposite wall of the colon (Figure 2A, green arrow). Once the snare was open enough, we torqued to the left and let the snare “fall on the polyp”, while the assistant slowly closed it, and I simultaneously pushed the snare towards the base of the polyp (creating the famous Y-catch trick) (Figure 2C). The polyp base was completely ensnared (1H) and we proceeded to perform the endoscopic mucosal resection, with R0 result (Figure 2D).
Figure 2. Top tricks to deal with difficult polyps (part 2)
In this case we used a Lariat snare, which has the advantage of having three different sizes in one snare (Figure 3). Figure 1A shows the small size, Figure 2B (intermediate size), and in Figure 2C the larger size is shown. The small size opening is ideal for cold-snaring small lesions.
Videos showing this endoscopic resection as well as Tips and Tricks for Submucosal Cushion, Dynamic Injection, ESD-EMR, Polypectomy State-of-The-Art, Creation of the Perfect india Ink Tattoo and everything related to colon polyp detection and resection are available on-demand in Endocollab.com
References:
-
Mönkemüller K, Neumann H, Fry LC, Ivekovic H, Malfertheiner P. Polypectomy techniques for difficult colon polyps. Dig Dis. 2008;26(4):342-6. doi: 10.1159/000177020. Epub 2009 Jan 30. PMID: 19188726.
-
Mönkemüller K, Neumann H, Malfertheiner P, Fry LC. Advanced colon polypectomy. Clin Gastroenterol Hepatol. 2009 Jun;7(6):641-52. doi: 10.1016/j.cgh.2009.02.032. Epub 2009 Mar 10. PMID: 19281865.
No COI by KM with any of the companies/utensils or products mentioned in this article. All photos taken by KM. Property of EndoCollab.
⚡ Power Up Your Skills: Related EndoCollab Courses
Download a PDF copy of this article
📚 Transform Difficult Cases into Success Stories
Dr. Mönkemüller’s techniques are part of EndoCollab’s comprehensive learning platform:
• Watch experts perform complex procedures
• Learn advanced techniques step-by-step
• Access our complete endoscopy education library
• Join a community of skilled endoscopists
Join EndoCollab today and transform your endoscopic skills!
