Video Endoscopic Sequence 1 of 29.

 Video Colonoscopic Polypectomy.

 A 55 year-old female, in a routine check-up, this mass was
 found at descending colon.

 Adenomatous tumor with a large and wide pedicle at
 descending was found. On the left lateral decubitus
 position, the tumor was thought to be sessile..
 A colonoscopy polypectomy was performed, first injecting
 the stalk with dilute epinephrine (1:10,000), and ligating
 devices such as a hemoclips and removed by transection of
 the stalk with a polypectomy snare.

 See the complete video endoscopic sequence.

 For more endoscopic features download the video clip by
 clicking on the endoscopic image if you would like to
 appreciate in full screen, wait to be downloaded the video
 complete then press Alt and Enter.
 All endoscopic images shown in this Atlas contains video
 clips.

Video Endoscopic Sequence 2 of 29.

Video Colonoscopic view of Colonic Polypectomy

Large multilobulated tumor is displayed.

 Approx. 95% of all colorectal cancers arise from adenoma,
 a finding that underscores the importance of treatment
 and surveillance of gastrointestinal adenoma.

 Some pedunculated polyps also may require advanced
 techniques, especially when the head is so large that it is
 difficult to see around the head of the polyp to seat the
 snare around its stalk.

Video Endoscopic Sequence 3 of 29.

 The long stalk of the polyp was exposed by rotating the
 colonoscope’s position.

 The incidence of invasive cancer increasing with size as
 there is a 50% chance of villous adenoma more than 1 cm
 been a cancer.

Video Endoscopic Sequence 4 of 29.

Endoscopic View of A large and wide pedicle Polyp.

 Large pedunculated polyps (> 2-3 cm) are often easily
 removed with standard snare cautery techniques. The
 difficulty most commonly encountered is when a large polyp
 has a particularly long stalk, and the head of the polyp
 prolapses in both directions when snaring is attempted.

Video Endoscopic Sequence 5 of 29.

 A dilution of adrenaline with 1/10.000 in dextrosa 50% was
 injected in the base of the wide pedicle.

Video Endoscopic Sequence 6 of 29.

Again more dilute epinephrine (1:10,000) such as used in the mucosectomy is performed.

Video Endoscopic Sequence 7 of 29.

 The tumor became ischemic, indicating that the blood
 supply of the tumor had vasoconstriction adequately.

Video Endoscopic Sequence 8 of 29.

Note that the tumor has been changed the color

Video Endoscopic Sequence 9 of 29.

Application of hemoclips.

 Resection of a pedunculated polyp with prophylactic
 hemoclips. A: pedunculated polyp with a 4.2-cm head and
 thick pedicle. hemoclips have been used prophylactically
 for thick-pedicle polyps prior to resection with an
 endoscopic snare.

Video Endoscopic Sequence 10 of 29.

 Endoscopic clip ligation of polyp stalk to prevent bleeding
 after snare polypectomy.

 In this image and the video clip shown that the first
 hemoclip has been relapsed and he second hemoclip is
 going to be relapsed.

Video Endoscopic Sequence 11 of 29.

Colonoscopic Snare Polypectomy

 Colonoscopic surveillance is recommended for patients
 with adenomas because the risks of new (metachronous)
 adenomas and colorectal cancer among these patients are
 greater — by a factor of 2 to 4 — than they are among
 persons without adenomas. However, these risks vary
 considerably according to the characteristics of the index
 adenoma. The recognition that a larger size and more
 advanced histologic features are independent risk factors
 for the presence of invasive cancer within an adenoma has
 led to the use of the term "advanced adenoma" for
 adenomas that are 1 cm or larger in diameter or that have
 any advanced histologic features (tubulovillous or villous
 histologic features or high-grade dysplasia).

Video Endoscopic Sequence 12 of 29.

A rapid cut current was applied to prevent burning at the clip site.

Video Endoscopic Sequence 13 of 29.

Again, A rapid cut current was applied to prevent burning at the clip site.

Video Endoscopic Sequence 14 of 29.

Video Endoscopic Sequence 15 of 29.

Being removed with a snare around its large stalk.

Video Endoscopic Sequence 16 of 29.

 Status post polypectomy, The large mass has been removed.

The success of colonoscopic polypectomy and surveillance depends on the identification and complete removal of the adenoma or adenomas.

Video Endoscopic Sequence 17 of 29.

Video Endoscopic Sequence 18 of 29.

 With the help with this basket, the resected mass is being
 retrieved.

Video Endoscopic Sequence 19 of 29.

Macroscopic image of the specimen.

Video Endoscopic Sequence 20 of 29.

Note the large and multilobulated tumor

Video Endoscopic Sequence 21 of 29.

Now the other side of the Tumor.

Video Endoscopic Sequence 22 of 29.

Video Endoscopic Sequence 23 of 29.

Video Endoscopic Sequence 24 of 29.

Polyp with a sessil pedicle

Video Endoscopic Sequence 25 of 29.

Lateral view of polyp

Video Endoscopic Sequence 26 of 29.

Normal colonic mucosa at the base of pedicle of the polyp

Video Endoscopic Sequence 27 of 29.

Low power of the tubulo villous microscopic pattern

Video Endoscopic Sequence 28 of 29.

A better detail of the histologic Picture

Video Endoscopic Sequence 29 of 29.

Tubulovillous microscopic pattern and conective tissue with vessels at the stromal support.

        Video Colonoscopic view of a Polypectomy.

 Colonoscopy and polypectomy are the most effective tools
 available to prevent colorectal cancer.

 Removal of polyps is an important method of prevention
 and cure of cancer of the colon.

 Adenomatous polyps are precursors of most colorectal
 cancers, and their prevalence increases with age. The
 chance of detecting adenomatous polyps at colonoscopy is
 generally independent of the indication for the procedure
 The practice of removing polyps at colonoscopy is based on
 the assumption that their removal prevents progression to
 cancer. This concept, often called the adenoma-carcinoma
 sequence.

 
                                           Medline.

Video Endoscopic Sequence 1 of 7.

Endoscopic view of Rectal Stalked Polyp.

 This 41 year-old male who undergone a routine colonoscopy which detected this polyp.

 The success of colonoscopic polypectomy and surveillance depends on the identification and complete removal of the adenoma or adenomas.

Video Endoscopic Sequence 2 of 7.

Removal of a Pedunculated Polyp.

Endoscopic polypectomy with diathermic loop.

 Initially, gastrointestinal endoscopy represented a useful
 diagnostic tool for digestive tract diseases. Yet, ever since
 Wolff and Shinya) introduced endoscopic polypectomy in
 the 1970’s, treatment of colorectal polyp has undergone a
 significant progress.

Video Endoscopic Sequence 3 of 7.

The snare loop is placed in the pedicle.

 Endoscopic snare resection using a monopolar diathermic
 polypectomy snare made of monofilament steel wire.

Video Endoscopic Sequence 4 of 7.

The remnants of the pedicle is being cauterized.

Video Endoscopic Sequence 5 of 7.

Dormia basket was used to retrieve the cut polyp.

Video Endoscopic Sequence 6 of 7.

The image and the video clip show the dormia basket that it used to retrieve the cut polyp.

Video Endoscopic Sequence 7 of 7.

 Argon plasma coagulators have been introduced to
 fulgurate large polyp remnants or for hemostasis with very
 positive results.

Video Endoscopic Sequence 1 of 23.

 Video Colonoscopic Polypectomy.

 A 43 year-old female, that has been presenting rectal
 bleeding for two months.
 Adenomatous polyp with a large and wide pedicle at
 sigmoid was found.
 A colonoscopy polypectomy was performed, first injecting
 the stalk with dilute epinephrine (1:10,000) in dextrosa
 50%, and ligating devices such as a triclip and removed by
 transection of the stalk with a polypectomy snare.
 See the complete video endoscopic sequence.


                                         Medline.  

Video Endoscopic Sequence 2 of 23.

Another image of the polyp.

Colonic adenomas are typically asymptomatic and are most commonly found by means of endoscopic or radiologic imaging studies performed because of unrelated symptoms or for colorectal cancer screening. Since at least 25% of men and 15% of women who undergo colonoscopic screening by experienced endoscopists are found to have one or more adenomas, the cumulative burden of subsequent surveillance colonoscopy on the health care system is substantial.

                                         Medline.

Video Endoscopic Sequence 3 of 23.

 This image and the video display the large and wide
 pedicle.
 

Video Endoscopic Sequence 4 of 23.

 Chromoendoscopy using indigo carmine.
 This method helps to enhance the recognition of details and
 reveal the otherwise invisible changes of the mucosa.







                                          Medline.

Video Endoscopic Sequence 5 of 23

High Magnification Colonoscopy.

Video Endoscopic Sequence 6 of 23.

 Chromoendoscopy with indigo carmine dye.
 

Video Endoscopic Sequence 7 of 23.

Amebic Ulcer.

 In addition to the polyp, we found through colonoscopy
 some multiple amebic ulcers, as well as diverticulae in the
 sigmoid. An amebic ulcer was found at sigmoid; multiple
 tiny ulcers were seen in the rectum and the cecum.
   

Video Endoscopic Sequence 8 of 23.

 In order to avoid an hemorrhage, we took prophylactic
 measures, such a dilution of adrenaline 2 cc with 1/10.000
 was injected in the base of the wide pedicle; after that, two
 triclip were applied to the base of the pedicle. 

Video Endoscopic Sequence 9 of 23.

 Most pedunculated polyps are removed by transection of
 the stalk with a polypectomy snare. The major risk with this
 approach is postpolypectomy bleeding. As a result, many
 endoscopists use one or more methods to reduce the risk of
 bleeding, particularly in polyps with wide stalks (pedicles
 larger than 1 to 1.5 cm in diameter).

Video Endoscopic Sequence 10 of 23.

 Note the white color that has been changed due to the
 injected dilution of adrenaline. (Vasoconstriction).

 It is considerably easier to snare polyps in the "six o'clock
 position" because the snare enters the field roughly at this
 orientation. The snare can be positioned over the polyp,
 which is subsequently captured by deflecting the tip of the
 colonoscope down.

Video Endoscopic Sequence 11 of 23.

 The TriClip´s

 (Endoscopic Clipping Device).

 The image and the video show the triclip.

 The principle of clip ligation for pedunculated polyps prior
 to polypectomy to stop bleeding or as a prophylactic
 measure to prevent bleeding.

Video Endoscopic Sequence 12 of 23.

Endoscopic clip application, The first triclip was applied.

 Metallic hemoclips have been endoscopically placed in the
 gastrointestinal tract for the treatment of bleeding lesions
 and closure of perforation. A further potential application
 is the ligation of the pedunculated polyps prior to
 polypectomy as a prophylactic measure to prevent
 bleeding.

Video Endoscopic Sequence 13 of 23.

 The second triclip is being applied to the base of the
 pedicle.

Video Endoscopic Sequence 14 of 23.

 Two triclips were applied to the base of the pedicle.

 Ligation using suture or metallic clips is a basic surgical
 technique to prevent postoperative bleeding. Generally,
 there are nourish blood vessels in the stalk of the
 pedunculated polyp, and their diameter depend on the size
 of the polyp and the diameter of the stalk. It is essential to
 completely ligate the vessels or to prevent postoperative
 bleeding for pedunculated polyp with or without active
 bleeding. 

Video Endoscopic Sequence 15 of 23.

 The two triclips are observed in the base of the wide
 pedicle.
 

Video Endoscopic Sequence 16 of 23.

 Transection of the stalk with a polypectomy snare.

Video Endoscopic Sequence 17 of 23.

 Note the traction used to avoid transmural injuries.

Video Endoscopic Sequence 18 of 23.

 The polyps have been falled out; the amebic ulcer is
 observed.

Video Endoscopic Sequence 19 of 23.

 Only complete excision permits accurate histological
 diagnosis. As a result, polypectomy should be considered
 as primarily a diagnostic procedure until histopathology
 confirms that the polyp has been completely removed.

Video Endoscopic Sequence 20 of 23.

 The resection site should be closely inspected for visible
 vessels.

Video Endoscopic Sequence 21 of 23.

 Histopathologic Image.

 This is the picture of a villous adenoma which shows some
 mild epithelial atypia.

Video Endoscopic Sequence 22 of 23.

Colonic mucosa at the base of the polyp with mild chronic inflamation.

Video Endoscopic Sequence 23 of 23.

Immunohistochemic stain for p53 positive in some of the nuclei of the polyp.

Video Endoscopic Sequence 1 of 35.

Endoscopic Resection of Giant Tubulo-Villous of
 the rectum.

 This is the case of a 57 year-old lady, who had been
 suffering of rectal bleeding during six months, patient only
 was under ointments and suppositories treatment, she was
 referred to our endoscopic unit for evaluation, with the
 anoscopy a mass was observed at first seemed small.
 With the digital examination the mass can be prolapsed
 through the anus as seem in this picture.

 A Giant Villous Adenoma: Mimicking Rectal Malignancy

Video Endoscopic Sequence 2 of 35.

The prolapsed mass seen at the colonoscopy

 Benign or malignant?

 Once a lesion is recognized and its size determined, the
 decision that must be made is whether or not the polyp is
 benign or malignant. There are few criteria that can be
 used to make the determination if any particular colonic
 lesion is malignant.

 A question that arises is whether or not to perform a biopsy
 and bring a patient back for polypectomy based on the
 subsequent results of biopsy or to depend on the visual
 impression of whether or not the polyp is benign.

Video Endoscopic Sequence 3 of 35.

 A Giant Tubulo-Villous Adenoma: Mimicking Rectal
 Malignancy.

 By practicing retroflexion in the rectum the mass is
 observed of a large size and appears to be adenocarcinoma.
 At this time we did not have any result of pathology and we
 decided to remove this tumor. Initially we thought it was
 small, Tumor consistency was soft.

Video Endoscopic Sequence 4 of 35.

 A Giant Villous Adenoma: Mimicking Rectal Malignancy

Another image of the irregular mass

 Usually, tubulu- villous adenomas are asymptomatic
 although they may cause rectal bleeding like malignant
 tumours.

Video Endoscopic Sequence 5 of 35.

 As at first the plan was to remove the tumor that appeared to be small, we decided to practice polypectomy in
fragments at this time we had no reported the biopsies
by pathology.

 Sessile polyps usually are considered somewhat difficult to
 remove, with the larger diameters falling into the ‘‘very
 difficult’’ category that requires advanced polypectomy
 techniques. Large polyps are defined as those over 20 mm
 or over 30 mm in diameter.

Video Endoscopic Sequence 6 of 35.

 Piecemeal Resection

 The rope with the loop diathermy, the fragment of large
 size prolapses outside of the anus. And there the
 polypectomy is performed.

Video Endoscopic Sequence 7 of 35.

There are many fragments of the neoplasia of villous appearance.

 Colorectal polypoid lesions have a risk for cancer
 development. Because of their malignancy potential and
 indistinguishable features from carcinoma at the diagnosis,
 they should be either excised or submitted for biopsy to
 assess further intervention. Adenomatous polyps are the
 most common type among other colorectal polyps. There
 are three common histopathological types of colorectal
 adenomatous polyps, namely tubular (67%), villous (5%)
 and tubulovillous (8%). Among them, villous adenomatous
 polyps have the greatest potential for cancer development.

Video Endoscopic Sequence 8 of 35.

More image and video clip observing the fragments of infiltrative appearance.

Video Endoscopic Sequence 9 of 35.

Then remove another piece of large size

Video Endoscopic Sequence 10 of 35.

Active bleeding is observed

 It has been well established that there is a greater risk of
 post polypectomy bleeding with larger polyps, ranging from
 2% to 24%.

 Therefore, the endoscopist should be familiar with
 endoscopic hemostasis techniques and this equipment
 should be readily available.

Video Endoscopic Sequence 11 of 35.

To stop this bleeding used the argon plasma, stopping the bleeding.

Video Endoscopic Sequence 12 of 35.

With the diathermy loop excising several remaining

 Retroflexion is a useful adjunctive procedure for the
 removal of some colon polyps proximal to the rectum that
 are difficult to access endoscopically. The use of
 retroflexion can increase the fraction of proximal sessile
 colon polyps amenable to endoscopic resection.

Video Endoscopic Sequence 13 of 35.

 More remaining are being resected with the loop diathermy.

Video Endoscopic Sequence 14 of 35.

Some fragments are attached to the dentate line

Video Endoscopic Sequence 15 of 35.

Continue excising pieces of this giant Tubulo-Villous adenoma in the dentate line.

Video Endoscopic Sequence 16 of 35.

Video Endoscopic Sequence 17 of 35.

We continue with the polypectomy of large fragments, retroflexed maneuver.

Video Endoscopic Sequence 18 of 35.

In this image and the video clip show almost the tumor has been resected.

Video Endoscopic Sequence 19 of 35.

Another large fragment.

Video Endoscopic Sequence 20 of 35.

The fragment was placed in a container of formalin.

Video Endoscopic Sequence 21 of 35.

Status after piecemeal excision

 In this image and video clip shows the status of
 endoscopic resection of this tumor: giant tubulo-villous of
 the rectum.

Video Endoscopic Sequence 22 of 35.

 Argon plasma coagulation of sessile polyp base after
 resection. Cautery is applied with argon plasma coagulator
 of micro remnants and the same time hemostasis.

Video Endoscopic Sequence 23 of 35.

Final status of endoscopic resection

 Although some polyps will require surgical removal, most
 can be removed by an experienced endoscopist. Familiarity
 with endoscopic hemostasis techniques is an important
 prerequisite for attempting the removal of large lesions.
 As experience and facility with advanced polypectomy
 techniques is accumulated, the endoscopist may
 progressively attempt more difficult lesions.

 I am sure this clinical case will have in some hands
 abdominoperineal resection performed and the patient
 condemned to carried out lifetime a permanent bag of
 colostomy.

 Two week after a follow up endoscopy was performed see
 below.

Video Endoscopic Sequence 24 of 35.

Photograph of some of the fragments

Macroscopic details of the removed tumor,

Video Endoscopic Sequence 25 of 35.

Base of polyp with vascular connective tissue and thermal effects.

Video Endoscopic Sequence 26 of 35.

Histopathology – Tubulovillous adenoma of rectum

Panoramic view of tubulovillous pattern.

Video Endoscopic Sequence 27 of 35.

Detail at higher magnification of the villi.

Video Endoscopic Sequence 28 of 35.

 Detail at high magnification of cellular atypia.

Video Endoscopic Sequence 29 of 35.

Shows the mucosa and submucosa of the polyp with the muscularis mucosae.

Video Endoscopic Sequence 30 of 35.

Two week after a follow up endoscopy was performed

 Shows the granulation tissue, multiple biopsies were taken,
 which showed no adenomatous tissue, however reinforced
 ablative therapy with argon plasma coagulator was
 performed and the plans to do another follow up endoscopy
 in three months.

Video Endoscopic Sequence 31 of 35.

More images and video clip of the scar

Video Endoscopic Sequence 32 of 35.

Again More images and video clip of the scar

Video Endoscopic Sequence 33 of 35.

 Reinforced ablative therapy with argon plasma coagulator
 was performed.

Video Endoscopic Sequence 34 of 35.

Continuing the ablative therapy

Video Endoscopic Sequence 35 of 35.

The final Status

Video Endoscopic Sequence 1 of 6.

Polypectomy of Stalked Polyp.

 Polyps with a large pedicle at the descending colon.

 This 58 year old male who undergone a colonoscopy as a
 medical control, in the same colonoscopy the polyp was
 snared .
 The histopathologic study displayed tubulovillous adenoma
 with dysplasia.

Video Endoscopic Sequence 2 of 6.

The form of the pedicle is observed.

 Polyps on a pedicle usually are removed readily with the
 snare and cautery technique. Some polyps are on an
 extremely long pedicle and can pose a problem for their
 removal because they tend to swing back and forth during
 the endoscopic examination.

Video Endoscopic Sequence 3 of 6.

With the polypectomy snare the polyp is fragmented.

Video Endoscopic Sequence 4 of 6.

 We continued with the technique of polypectomy in
 fragments.

Video Endoscopic Sequence 5 of 6.

More fragments.

Video Endoscopic Sequence 6 of 6.

The final status of the endoscopic polypectomy is observed.

Video Endoscopic Sequence 1 of 4.

 Video Colonoscopic view of a polypectomy of a big
 6 cm. x 4 cm. sessile lesion.
 The pictures showed below are the sequence of the
 removal.



                                         Medline.

Video Endoscopic Sequence 2 of 4.

 Note the traction is being performed when the enormous
 lesion is being removed.
 






                                           Medline.

Video Endoscopic Sequence 3 of 4.

 Status Post Videoendoscopic polypectomy of a huge sessile
 adenoma. The video clip displays the bleeding and
 cauterization.






                                           Medline.

Video Endoscopic Sequence 4 of 4.

Status Post Polypectomy.

 8 days after the endoscopic procedure, The ulcer is
 already healing.

        

Video Endoscopic Sequence 1 of 2.

Enormous Sessile Adenoma of the Rectum.

 The primary clinical importance of colorectal adenomas is
 their well-recognized relationship to colorectal cancer. An
 abundance of scientific data indicate that almost all
 colorectal cancers arise from previous benign adenomas.
 Compelling evidence for this polyp-cancer sequence
 includes their similar prevalence in different world
 populations, their common etiology, and their similar site
 distribution in the colon.
  

Video Endoscopic Sequence 2 of 2.

 This tumor was removed completely with the snare
 polypectomy. The procedure was carried out in three
 different days with piecemeal excision.  

Polypectomy of a stalked polyp.

Video Endoscopic Sequence 1 of 2.

Endoscopic polypectomy.

 An attempt should be made to bring all polyps into the six
 o'clock position to facilitate snare placement, and this can
 usually be accomplished by rotation of the colonoscope
 relative to the polyp.

Video Endoscopic Sequence 2 of 2.

 The polyp has been fallen out.

Video Endoscopic Sequence 1 of 5.

 Endoscopic snare excision of large pediculated polyp.
 This sequence displays a polypectomy of long stalked
 Polyps at the transverse colon near splecnic flexure.

 

Video Endoscopic Sequence 2 of 5.

 Placement of a snare wire over the stalk of the polyp.

 

Video Endoscopic Sequence 3 of 5.

 Cautery is applied to the wire loop, which was tightened
 around the stalk of the polyp.

Video Endoscopic Sequence 4 of 5.

 The video clip displays the cutting of the polyp.
 

 

Video Endoscopic Sequence 5 of 5.

 Snaring the stalk.

Argon Beam Coagulation

 The image and the video clip display a diminutive polyp
 that was removed with coagulation, using argon plasma
 coagulator (APC).
 Small sessile polyps are resected, using several different
 techniques, including hot and cold biopsy (with and without
 cautery), hot or cold minisnare, or cold biopsy followed by
 fulgeration with a monopolar or bipolar electrode. The
 monopolar hot biopsy forceps should be used with great
 caution in the thin-walled right colon. There have been
 reported perforations and a relatively high rate of delayed
 bleeding using this device. When using any type of cautery
 probe in the right colon, it is important to apply low-power
 cautery cautiously without pressing the tip of the probe into
 the bowel wall. Even modest pressure can thin out the wall
 and increase the chance of perforation.