How would you remove this pedunculated polyp (Paris 0-Ip, Kudo IIIL)?

TECHNIQUE ARTICLE

Keywords: pedunculated polyp; Paris 0-Ip; Kudo IIIL; sigmoid polypectomy; prophylactic hemoclip; pedicle hemostasis; endoloop; underwater polypectomy; anticoagulation; post-polypectomy bleeding

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Clinical Scenario

A 60-year-old man with a history of hypertension, coronary artery disease, and atrial fibrillation on apixaban (Eliquis) — held two days before the procedure — was referred for screening colonoscopy. In the sigmoid colon we encountered a large pedunculated polyp with a thick stalk and a prominent head. The lesion was classified as Paris 0-Ip with a Kudo IIIL surface pit pattern, consistent with a tubular or tubulovillous adenoma.

Endoscopic Findings

The polyp measured roughly 25–30 mm at the head with a stalk of comparable thickness — a configuration that should immediately raise the suspicion of a sizeable feeding artery within the pedicle. Three features collectively predict a vessel of clinical importance:

• A large polyp head — bigger heads need more blood flow for "nutrition," so the supplying artery scales accordingly.
• Advanced adenomatous features — neoplastic progression correlates with angioneogenesis; the more dysplastic the head, the richer the microcirculation.
• A thick stalk — the mechanical caliber of the pedicle directly tracks the caliber of the feeding vessel.

This polyp had all three.

The Question

Before reading on, ask yourself: how would you resect this polyp?

1. Just snare
2. Pre-injection and then snare
3. Snare and then clip
4. Pre-clipping and then snare
5. Inject, clip, and snare
6. Inject, snare, and then clip the stump
7. Place an endoloop and then snare
8. Snare and then place an endoloop
9. Underwater snare resection
10. Other

Discussion: Choosing the Approach

The honest answer is that all of these options can be correct — endoscopists have successfully removed pedunculated polyps every one of these ways. The real question is not whether a technique can work, but whether it gives you the safest, most predictable outcome for the patient in front of you. Many endoscopists prefer to cut first and then provide prophylactic or active hemostasis. That sequence is reasonable for small, thin-stalked polyps in low-risk patients. But it is genuinely risky in this scenario: post-resection bleeding from a thick pedicle can be brisk, especially in patients on anticoagulation or those with bleeding diatheses or dyscrasias. By the time you are scrambling to suction blood and identify the bleeding point, you are no longer in control of the field. I prefer to always perform prophylactic hemostasis BEFORE polyp resection in this setting. The most practical way to provide that prophylactic hemostasis is with hemoclips. (For a deeper look at clip selection and deployment mechanics, see our companion pieces on mastering the use of hemoclips and tips for placement of clips for hemostasis.) When available, endoloops are quite useful and equally safe — but placing a loop in angled positions such as the sigmoid colon can be challenging, and the loop has to sit at the right level on the stalk. A small pre-injection of saline, or saline with epinephrine 1:20,000, into the base can also help create a temporary tamponade and decrease blood flow to the polyp head. The trade-off is that injection can deform the stalk and make subsequent snare placement more awkward. Underwater or saline-submerged resection is another option I lean on increasingly; it offers two advantages: less thermal tissue damage during cutting, and dilution of any post-polypectomy bleeding with a clearer visual field. (We discuss underwater resection technique in cases such as endoscopic resection of a large duodenal lipoma and resection of a giant gastric polyp to treat upper GI bleeding.)

Endoscopic Technique

In this case we opted for pre-clipping with two hemoclips, followed by hot snare resection above the clips, proximal to the polyp head.

1. Position the polyp at 6 o'clock in the field, with the stalk fully visualized. Adequate insufflation and a clean field matter — washing and suction first pays off.
2. Deploy the first clip at the base of the pedicle, perpendicular to the stalk axis, capturing as much of the stalk thickness as the clip span allows.
3. Deploy the second clip just adjacent to the first, slightly overlapping if needed, to ensure complete mechanical occlusion of the central vessel.
4. Place the snare above the clips, leaving a small cuff of stalk tissue between the clips and the snare. This cuff protects the clips from being incorporated into the cautery cut and gives you a stump you can re-clip if needed.
5. Resect using hot snare, with blended or pure-cut current per your institutional preference. Retrieve the specimen.
6. Inspect the stump. If the clips are intact and the field is dry, you are done. If you see any oozing or a visible vessel, place an additional clip on the stump.

Look at that stalk again. That was a substantial feeding vessel — exactly the kind of artery that produces a textbook arterial squirter when transected without prophylaxis. The pre-clip was the right call.

Practical Pearls

• For any pedunculated polyp with a head ≥10 mm or a thick stalk, default to prophylactic mechanical hemostasis — clips or loop — rather than reactive treatment.
• Two clips beat one. The central vessel can sit slightly off-center; doubling up improves your odds of complete occlusion.
• Always leave a tissue cuff between the prophylactic clips and the snare cut so you preserve a re-treatable stump.
• In a tough sigmoid angulation where you cannot get a loop seated, do not force it — use clips.
• Inspect the resected pedicle. The visible vessel is both your quality check and your teaching slide.