Video Endoscopic Sequence 1 of 37.

 Case on Multiple Adenomas (large polyps) of the Rectum.

 This 34 year-old male, present four months with rectal
 bleeding with mucoid secretion, pujo and tenesmus.
 Colonoscopy displays multiple ulcerated polyps.
 They are located from the pectin line to recto-sigmoid
 junction, the other segment of the colon were negative to
 the cecum for colonic lesions.
 In order to diminish the size of the large polyps and mass,
 argon plasma coagulator was used, then a combined
 therapy will be use to removal them or the patient will need
 a surgery.

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 screen mode.

Video Endoscopic Sequence 2 of 37.

 Case on Polyposis of the Rectum.

 This mass located in the first rectal valve, has the image of
 adenocarcinoma but the biopsies have been negatives.
 There are several polyps nearby.

 Until now the multiple biopsies display tubulos-Villous
 Adenoma.

 Biopsies of polyps to assess for malignant foci are
 inadequate. Only complete excision permits accurate
 histological diagnosis. As a result, polypectomy should be
 considered as primarily a diagnostic procedure until
 histology confirms that the polyp has been completely
 removed.

Video Endoscopic Sequence 3 of 37.

Difficult Polypectomy.

To be too difficult to be removed endoscopically.?

 Generally some criteria are acceptable that Which Patients
 Should Be Treated Initially With Surgical Resection
 (1) polyps that laterally encompass more than one third of
 the bowel circumference; (2) those that extend
 longitudinally over 2 successive haustral folds; (3) lesions
 that grossly appear to be malignant (eg, irregular, friable,
 firm/hard, ulcerated, bleeding); and (4) polyps that extend
 into the appendix, a diverticulum, or the ileocecal valve, or
 otherwise wrap around a sharp fold.
 

Video Endoscopic Sequence 4 of 37.

There are several ulcerated polypoid mass in the rectum.

 Large polyps are in fact associated with a higher rate of
 complications. Some polyps will require surgical removal,
 but the best gauge of whether a given endoscopist should
 attempt removal is the degree of experience and level of
 comfort of that endoscopist.

Video Endoscopic Sequence 5 of 37.

This polyps are seen near of the recto sigmoid junction.

Video Endoscopic Sequence 6 of 37.

White spots.

The mucosa of the rectum is found with hyperplasic foci.

Video Endoscopic Sequence 7 of 37.

 White spots are arrangements of foamy cells at the
 periphery of a tumor. Most frequently found in association
 with cancers and large adenomas.

 A close up of the images, using a magnifying endoscope.

Video Endoscopic Sequence 8 of 37.

The image and the video clip display multiple soft polyps.

Video Endoscopic Sequence 9 of 37.

 Interventional Endoscopy: Using of Argon Plasma Coagulator.

 The therapeutic treatment it has been planned to diminish
 the size of all rectal polyps of our patient. We will try to
 make so many applications as they are necessary.

 Argon-plasma coagulation is based on the transmission of a
 high-frequency current through argon gas to result in
 thermal damage. It has been safely and efficaciously used
 in multiple settings.

Video Endoscopic Sequence 10 of 37.

High power setting Argon Plasma Coagulation.

 We evaluated the efficacy of a thermal energy source, the
 argon plasma coagulator, to diminish the size of all
 rectal adenomas so they will be snare or will be under a
 combined therapeutic approach.

 It conducts monopolar electrosurgical current to tissue via
 an ionized argon gas stream (argon plasma) that is
 delivered from a small tube that emanates from the
 colonoscope. The argon gas is ignited and charged and
 cause a superficial destruction of these abnormal blood
 vessels and stops the radiation related bleeding. The APC
 procedure is performed on an outpatient basis and requires
 only light or no sedation. APC is consider not only
 effective, but very safe.

Video Endoscopic Sequence 11 of 37.

 High power setting Argon Plasma Coagulation.

 Argon-plasma coagulation (APC) has been used safely and
 efficaciously in multiple settings including colon polyp
 treatment.

 The image and the video show the argon plasma
 coagulating the polipoids tissues.
 forward viewing probe is fired in a noncontact fashion to
 spot weld the lesions.

Video Endoscopic Sequence 12 of 37.

High power setting Argon Plasma Coagulation.

 Argon Plasma Coagulation, or APC for short, is a new
 method of electrocoagulation. As a result, it allows for
 the non-contact application of electrical energy to
 achieve tissue destruction or hemostasis
 (the ability to stop bleeding). APC uses high frequency
 electrical current delivered via ionized argon gas.
 This gas, being ionized, allows for the conduction of
 electricity, thus leading to the term "argon plasma".     

Video Endoscopic Sequence 13 of 37.

A forward firing probe is used to fulgurate individual sites.

 Firstly, argon gas is emitted from the end of the probe
 running through the endoscope channel. Next,
 high-frequency current is discharged from an
 electrosurgery unit. When argon gas becomes electrically
 conductive ( argon plasma ) this allows the current to reach
 the targeted mucosa of the tissue which is coagulated
 shallowly and uniformly.
 The device is especially effective for the coagulation of
 hemorrhages on the surface of the tissue.

Video Endoscopic Sequence 14 of 37.

 This image shows a large of the mass that has been
 coagulated.

 Colonoscopic polypectomy is preventing colorectal cancer.
 Videoendoscopy and new perendoscopic hemostasis
 techniques make endoscopic polypectomy of large colonic
 polyps an alternative to the surgical approach.

Video Endoscopic Sequence 15 of 37.

 Appearance post two sessions of therapeutical ablation.

 Follow up endoscopes have been performed as well as
 therapeutical approach with argon plasma coagulator.
 This sequence from the 15 to 21 is the third one that has
 been performed.
 

Video Endoscopic Sequence 16 of 37.

 This image as well as the video clip show from the
 pectin line to the first rectal valve with a mass which
 have had partially ablation with argon plasma coagulation
 in addition some briedge are observed from the mass to
 the pectin line..
 
 

Video Endoscopic Sequence 17 of 37.

Rectum in retroflexed maneuver.

Multiple polyps are observed.

Video Endoscopic Sequence 18 of 37.

Rectum in retroflexed maneuver.

 An ulcerated polyp that was previously undergone ablative
 therapy with argon plasma is observed. 

Video Endoscopic Sequence 19 of 37.

 The mass of the first rectal valve appears that have been
 diminish with the two previous therapy with APC.

Video Endoscopic Sequence 20 of 37.

 The image and the video clip shows the new therapy with
 APC.

 Argon-plasma coagulation (APC) has been used in digestive
 endoscopy since 1991, when a specific electrode that could
 be introduced through the endoscope channel was designed.
 It is a monopolar electrosurgical device that does not need
 physical contact with tissue, as a high-frequency electrical
 current is transmitted to the tissue by ionized argon gas.
 APC produces superficial thermal damage about 2-3 mm
 deep depending on energy output and the time current is
 applied.

Video Endoscopic Sequence 21 of 37.

 Argon Plasma Coagulator Therapy.

 The non-contact nature of the therapy also allows for the
 more rapid treatment of large areas of tissues, shortening
 procedure time. In addition, although the depth of tissue
 injury depends on the power setting and duration of
 application, it appears more limited (0.5 ­ 3.0 mm) than the
 injury caused by laser therapy. This offers the advantage,
 at least theoretically, of a decreased risk of perforation
 during therapy.

Video Endoscopic Sequence 22 of 37.

The fourth session.

(Sequence 22 to 29), We used Combined Therapeutical
 methods APC and Mucosectomy,

 Large sessile polyps are more likely to have neoplastic
 foci, with a high rate of recurrence after excision, as well as
 a higher frequency of postpolypectomy complications such
 as bleeding and perforation. For these reasons, alternative
 ways of destroying residual tissue with a lower percentage
 of complications have been researched, usually associated
 with piecemeal polypectomy. Diverse results have been
 reported on the use of argon plasma coagulation.

Video Endoscopic Sequence 23 of 37.

More images and video clips of this sequence.

Video Endoscopic Sequence 24 of 37.

A close up magnification using a magnifying colonoscope.

Video Endoscopic Sequence 25 of 37.

The mucosal bridge from the pectin line to the mass has been coagulated.

Video Endoscopic Sequence 26 of 37.

A close up magnification using a magnifying colonoscope.

Video Endoscopic Sequence 27 of 37.

More coagulation with argon plasma.

Video Endoscopic Sequence 28 of 37.

Again more coagulation with argon plasma.

Video Endoscopic Sequence 29 of 37.

 Some blocks of biopsies were got with the diatermia
 snare.

 Follow-up colonoscopy will be performed soon, as well as
 the therapeutic approach. This case will be continued soon,
 and more images and video clips will be reported here on
 this clinical case, but long term follow-up will be necessary.
 To the last colonoscopy with multiple biopsies, no
 malignancies were detected, see the histopathological
 below.

Video Endoscopic Sequence 30 of 37.

 Appearance post polypectomy of larges masses of the
 rectum.

 The image and the video display here shows the successful
 irradication of the first masses displayed in the sequences
 2,3 4 of this case.

 This image and the video clip represented the status of
 four treatments with APC and Combined Therapeutical
 methods with mucosectomy EMR endoscopic mucosal
 resection. No malignant evidence has been found until this
 moment. There are some deep ulcers, The masses
 disappeared, A follow-up colonoscopy in 3-6
 months is advisable to determine whether resection was
 complete.

Video Endoscopic Sequence 31 of 37.

More images and video clips.

 If residual polyp is present, it should be resected and the
 completeness of resection should be recheched in another
 3-6 months.

 Sequence 32 of 37.

 A tubular pattern is shown with chronic inflammation at the
 surface of the polyp.

 Sequence 33 of 37.

There are superficial inflammation and there are not atypias.

 Sequence 34 of 37.

Superficial ulceration of the polyp with purulent exudate.

 Sequence 35 of 37.

 Another biopsy with cryptic patern and ulceration of the
 surface.

 Sequence 36 of 37.

 The villous pattern is clearly shown.

.

 Sequence 37 of 37.

 Ulcer of the polyp with inflammatory changes of the crypts.

 Video Endoscopic Sequence 1 of 46.

 Laparoscopically Surgery for Colonic Perforation with
 Peritonitis.

 This is the case of a 51 year-old female, that underwent a
 polypectomy of a polyp in the cecum that was carried out in
 another clinic, ten hours after that patient began with mild
 abdominal pain located in the right iliac fossa, the abdomen
 was soft and tender and no rebound was detected.
 Laboratory tests indicated an elevated White cell count of
 16 500 with 82.9% neutrophils, patient was hospitalized
 with the presumptive diagnosis of transmural burn
 syndrome.

 Post polypectomy electrocoagulation syndrome (also known as
 postpolypectomy syndrome and transmural burn syndrome)
 refers to the development of abdominal pain, fever, leukocytosis,
 and peritoneal inflammation in the absence of frank perforation
 that occurs after polypectomy with electrocoagulation
 Recognition of postpolypectomy syndrome is important to avoid
 unnecessary exploratory laparotomy since it resolves with
 conservative treatment in the majority of patients.

 Postpolypectomy syndrome develops when electrical current
 applied during polypectomy extends past the mucosa into the
 muscularis propria and serosa, resulting in a transmural burn
 without perforation . Serosal irritation leads to a localized
 inflammatory response that manifests clinically as a localized
 peritonitis.

 The second day in the hospital, patient had a severe
 abdominal paint with felling of shortness of breath, with
 abrupt onset of acute abdomen with severe generalized
 abdominal pain, tenderness, and peritoneal signs. Pain was
 radiated to the shoulder, An abdominal series (supine and
 upright abdominal x -rays and chest x-rays), showing free
 air under the diaphragm. The transmural burn syndrome
 had evolved to colon perforation.

 This was managed successfully by exploratory laparoscopy
 and peritoneal lavage with drainage. The perforation was
 repaired at a laparoscopy using intracorporeal suturing.

Video Endoscopic Sequence 2 of 46.

The fibropurulent exudate are being aspirated

 The post surgical period patient had generalized Sepsis
 that was management with antibiotics and dopamine.

Video Endoscopic Sequence 3 of 46.

The exact site of the perforation has been located in the cecum.

 Full thickness diathermy injury resulting in delayed
 perforation at the damage site.

Video Endoscopic Sequence 4 of 46.

More images and video clips of the perforation´s hole

 Colonoscopy is a powerful diagnostic and therapeutic procedure
 with a recognized risk of complications ranging from perforation
 to hemorrhage and septicemia. Perhaps the most dangerous
 complication associated with this procedure is bowel perforation.

Video Endoscopic Sequence 5 of 46.

The hole of the perforation is exposed

 Major risks associated with large polypectomy with
 conventional monopolar snare polypectomy are bleeding
 and perforation. Bleeding occurs when too little current is
 used and perforation usually occurs when too much current
 is used.
 

Video Endoscopic Sequence 6 of 46.

The laparoscopic repair with mechanic suturing stapler is initiated.

Video Endoscopic Sequence 7 of 46.

Video Endoscopic Sequence 8 of 46.

Video Endoscopic Sequence 9 of 46.

Video Endoscopic Sequence 10 of 46.

After mechanic suture was performed reinforcement with manual suture is being made.