How Would You Remove This Pedunculated Polyp (Paris 0-Ip, Kudo IIIL)?

Diana L. Dougherty; Klaus Mönkemüller

GI Endoscopy · 2 min read

How Would You Remove This Pedunculated Polyp (Paris 0-Ip, Kudo IIIL)?

A large sigmoid 0-Ip polyp in a patient on Eliquis. Ten ways to resect it, and why prophylactic hemostasis comes before the cut.

ByDiana L. Dougherty, MD, MPH andKlaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

**Figure 1:** Large pedunculated polyp (Paris 0-Ip, Kudo IIIL) in the sigmoid colon.

A 60-year-old man with a history of hypertension, coronary artery disease, and atrial fibrillation on Eliquis (stopped 2 days before colonoscopy) was found to have a large pedunculated polyp in the sigmoid colon.

Question

How would you resect this polyp?

Just snare
Pre-injection and then snare
Snare and then clip
Pre-clipping and then snare
Inject, clip, and snare
Inject, snare, and then clip the stump
Place an endoloop and then snare
Snare and then place an endoloop
Underwater snare resection
Other

Answer

All options are correct. However, when dealing with pedunculated polyps, consider that there is always a large feeding vessel going through the pedicle. Clues to the presence of larger vessels are a) a large polyp head (needs more blood flow for "nutrition"), b) advanced adenomatous features (which correlate with neoplasia and angioneogenesis, i.e., more vessels/microcirculation in the polyp head), and c) thickness of the stalk or pedicle.

Many endoscopists prefer to cut first and then provide prophylactic or active hemostasis. However, this option may be risky, as post-resection bleeding may be brisk, especially in patients on anticoagulation or those who have bleeding diathesis or dyscrasias. Thus, I prefer to always perform the prophylactic hemostasis BEFORE polyp resection.

The most practical way to provide hemostasis is using hemoclips. If available, endoloops are quite useful and safe. Nevertheless, placing loops in angled positions such as the sigmoid colon can be challenging. Using a little 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. However, sometimes injection can deform the stalk and make subsequent resection more challenging. Using underwater or saline-submerged resection has the advantages of a) less tissue damage during cutting and b) dilution of any post-polypectomy bleeding, with improvement of the visual field.

Pre-clipping of the stalk with hemoclips, the transected stalk with a large feeding vessel circled, and the resected specimen with the vessel marked by an arrow — **Figure 2:** Pre-clipping using two clips, followed by hot snare resection above the clips. The stalk (yellow circle) and the big feeding vessel (yellow arrows).

In this case we opted for pre-clipping using two clips, followed by hot snare resection above the clips, proximal to the polyp head. Look at the stalk (yellow circle). Wow, that was a big feeding vessel! (yellow arrows). The choice of pre-clipping was great!

About the authors

Diana L. Dougherty, MD, MPH

Associate Program Director, Gastroenterology Fellowship

Carilion Clinic / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Diana L. Dougherty, MD, MPH, is the Associate Program Director of the Gastroenterology Fellowship at Carilion Clinic and Virginia Tech Carilion School of Medicine in Roanoke, Virginia. She earned her medical degree from Drexel University College of Medicine and completed her internal medicine residency at the National Capital Consortium before joining the Carilion gastroenterology faculty after fellowship training.

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

Editor-in-Chief, The Practicing Endoscopist

Professor of Medicine, Carilion Memorial Hospital / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE, is the editor-in-chief of The Practicing Endoscopist and the founder of EndoCollab. He is Professor of Medicine at Virginia Tech Carilion School of Medicine and a practicing endoscopist at Carilion Memorial Hospital in Roanoke, Virginia.

Dr. Mönkemüller has published extensively on endoscopic techniques and devices, with a particular focus on therapeutic endoscopy, foreign body removal, GI bleeding, and the use of caps and accessories in everyday practice. He lectures internationally and has contributed to multiple GI endoscopy textbooks and atlases.

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