Colonoscopic view of a Polypectomy.
Video Colonoscopic view of a Polypectomy.

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.

Nowadays, the number of cases in which malignant colorectal polyps are removed is increasing due to colorectal cancer screening programmes.

 

 

 

Endoscopic view of Rectal Stalked Polyp.

Video Endoscopic Sequence 1 of 8.

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.

Adenomatous polyps are tumors of benign neoplastic epithelium with variable potential for malignancy. The adenoma-carcinoma sequence is well known and it is accepted that more than 95% of colorectal cancers arise from adenomas.

 

 

Endoscopic view of Rectal Stalked Polyp


Removal of a Pedunculated Polyp.

Video Endoscopic Sequence 2 of 8.

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.

Polypectomy of a Pedunculated Polyp.

Video Endoscopic Sequence 3 of 8.

The snare loop is placed in the pedicle.

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

The World Health Organisation (WHO) classifies adenomas into tubular (less than 20% villous architecture), tubulovillous and villous, with approximately 87% of adenomas being tubular, 8% tubulovillous and 5% villous. Only 5% of adenomas are in danger of becoming malignant. The probability of high grade dysplasia and of carcinomatous transformation increases with polyp size, especially when they are larger than 1 cm, they have a villous component, there are many polyps or the age at diagnosis is more than 60 years. The neoplasia is considered to be advanced when polyps are 1 cm or more in diameter, there is a villous component or a high degree of dysplasia. More than 25% of advanced polyps and colon cancers are located in the area proximal to the splenic flexure. Mixed polyps also have the ability to become malignant, as does hyperplastic polyposis syndrome.

 

Polypectomy of a Pedunculated Polyp.

Video Endoscopic Sequence 4 of 8.

Polypectomy of a Pedunculated Polyp.

The remnants of the pedicle is being cauterized.

Polypectomy of a Pedunculated Polyp.

Video Endoscopic Sequence 5 of 8.

Dormia basket was used to retrieve the cut polyp.

Polypectomy of a Pedunculated Polyp.

Video Endoscopic Sequence 6 of 8.

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

Polypectomy of a Pedunculated Polyp.

Video Endoscopic Sequence 7 of 8.

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

Polypectomy of a Pedunculated Polyp.

Video Endoscopic Sequence 8 of 8.

Two years later a follow up endoscopy was practiced finding the polypectomy scar.

Video Colonoscopic Polypectomy of a Giant polyp

Video Endoscopic Sequence 1 of 23.

Video Colonoscopic Polypectomy of a Giant polyp

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.

Endoscopy of Giant Polyp Polypectomy

Video Endoscopic Sequence 2 of 23.

Endoscopy of Giant Polyp Polypectomy

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.


Endoscopy of Giant Polyp Polypectomy

Video Endoscopic Sequence 3 of 23.

Endoscopy of Giant Polyp Polypectomy

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

Morphology is described as polypoid (pedunculated or sessile) and nonpolypoid (flat or ulcerated) subtypes according to the Paris classification]. The endoscopist should be alert to some features that are suggestive of possible malignancy. These features include the size, the presence of depressed ulceration, irregular contours, deformity, a short and immobile stalk and the inability to elevate a sessile polyp when a submucosal bleb is formed. Nonpolypoid colorectal neoplasms have a greater association with carcinoma (NHGN or submucosal invasive carcinomas) compared with polypoid neoplasms, irrespective of size. Attempts at diagnosis in such suspicious lesions, as well as in flat or depressed lesions, can be carried out using chromoendoscopy and magnification techniques that can highlight abnormalities of glandular cytoarchitecture, while also revealing information concerning the extent of submucosal invasion.

 

Endoscopy of Giant Polyp Polypectomy

Video Endoscopic Sequence 4 of 23.

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

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

 

Endoscopy of Giant Polyp Polypectomy

Video Endoscopic Sequence 5 of 23.

High Magnification Colonoscopy.

Endoscopy of Giant Polyp Polypectomy

Video Endoscopic Sequence 6 of 23.

Chromoendoscopy with indigo carmine dye.

Endoscopy of Giant Polyp Polypectomy

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.

Endoscopy of Giant Polyp Polypectomy

Video Endoscopic Sequence 8 of 23.

In order to avoid an hemorrhage, prophylactic measures were implemented, 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 Colonoscopic Polypectomy of a Giant polyp

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).

Gigant Polyp

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.

Endoscopy of Giant Polyp Polypectomy

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.

Endoscopy of Giant Polyp Polypectomy

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.

Gigant Polyp

Video Endoscopic Sequence 13 of 23.

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

Endoscopy of Giant Polyp Polypectomy

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.

Gigant Polyp

Video Endoscopic Sequence 15 of 23.

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

Gigant Polyp

Video Endoscopic Sequence 16 of 23.

Transection of the stalk with a polypectomy snare.

Gigant Polyp

Video Endoscopic Sequence 17 of 23.

Note the traction used to avoid transmural injuries.

Gigant Polyp

Video Endoscopic Sequence 18 of 23.

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

Gigant Polyp

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.

Gigant Polyp

Video Endoscopic Sequence 20 of 23.

The resection site should be closely inspected for visible vessels.

Gigant Polyp

Video Endoscopic Sequence 21 of 23.

Histopathologic Image.

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

Gigant Polyp

Video Endoscopic Sequence 22 of 23.

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

Gigant Polyp

Video Endoscopic Sequence 23 of 23.

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

giant  polyp resection

Video Endoscopic Sequence 1 of 20.

Endoscopic polypectomy giant mass of the recto-sigmoid junction.

52 year-old female, who had been with intermittent episodes of hematochezia At colonoscopy this mass was found.

Histopathology reveals a tubulovillous adenoma.

Surrounding the base of the tumor there is a Chicken skin mucosa

 

giant polyp

Video Endoscopic Sequence 2 of 20.

Sessil multilobulated mass

Submucosal injection for polypectomy

The submucosal injection technique is often used for removal of large sessile adenomas. Deyhle et al. first performed submucosal injection to raise flat mucosal lesions facilitating ensnaring in 1973. Saline or epinephrine solution (1 : 20 000) is injected from the margins of the polyp. Submucosal injection may be useful to lift parts of the polyp located in the appendiceal orifice or behind a haustral fold. However, submucosal injection even with large amounts of saline solution may not avoid perforation, if too large pieces of polyp are ensnared and resected. Diluted epinephrine solution is used to prevent bleeding during polypectomy. However, a possible drawback of this precaution may be delayed bleeding due to the short-lasting vasoconstrictive effect of epinephrine.

Endoscopic mucosal resection (EMR) using a double-channel endoscope was introduced by Tada et al. in 1993] to remove large sessile and flat polyps. The lesion is lifted by using a forceps to enable ensnaring ('lift and cut' technique). Several modifications of EMR technique have been introduced in the management of early cancer of the stomach and esophagus.

In the colon and rectum, EMR is widely performed using the simple snare resection technique. The colon wall is 1.5–2.2 mm in total thickness, and thermal damage to deep layers of the colon is frequently encountered. Injection of fluid into the submucosa beneath the polyp will increase the distance between the base of the polyp and the serosa. When current is then applied via a polypectomy snare, the lesion can be more safely removed because of a large submucosal 'cushion' of fluid which lessens the likelihood of thermal injury to the serosal surface.

 

giant polyp

Video Endoscopic Sequence 3 of 20.

Endoscopic Removal of Large and Difficult Colon Polyp

Endoscopic polypectomy starts with infiltration of adrenaline solution 1 / 10,000 in 50% dextrose.

Note the effect of vasoconstriction by color changes of the mass.
Surrounding the base of the tumor there is a colonic chicken skin mucosa: an endoscopic and histological abnormality adjacent to colonic neoplasms.

It is permissible to remove a much larger piece with this technique than one would ordinarily resect when in the right colon without a 'cushion' of fluid. The pieces should probably not be larger than 2 cm in diameter. With the fluid as protection against deep thermal tissue injury, it is possible to fulgurate the base of the resection site with devices such as a hot biopsy forceps, the tip of the snare, the argon plasma coagulator, or any other thermal device which delivers heat to the residual polyp site.

giant polyp colon

Video Endoscopic Sequence 4 of 20.

The image and the video show the beginning of cut fragments of large size in order to devastate this mass to its base.

There is no standardized definition of difficult polyps. However, polyps become difficult and challenging to remove endoscopically when they are large in size, flat in nature, situated in a high-risk location and when access to them is very awkward.

 

giant polyp

Video Endoscopic Sequence 5 of 20.

In the video clip as well as the endoscopic image there are multiple fragment they were cut with polypectomy, needing to cut more fragments.

There are no well-defined criteria to define a difficult polyp. A number of factors can make removal of a polyp difficult. These factors can be summarized into those related to difficult morphology and those related to difficult location. Factors related to difficult morphology include size (greater than 2 cm for sessile polyps and greater than 3 cm for pedunculated polyps), polyps occupying more than one third of the luminal circumference and polyps crossing 2 haustral folds. Factors relating to location include peridiverticular polyps, rectal polyps close to the dentate line, polyps over the ileo-cecal valve or appendicear orifice, and clamshell polyps (polyps wrapped around a fold).

 

giant polyp

Video Endoscopic Sequence 6 of 20.

Continuing to devastate this mass

Difficult morphology

Size is the most commonly encountered factor in most series. With increasing size, the risk of complications, recurrence and malignancy also increase. Most endoscopists are trained to resect polyps less than 20 mm. Polyps greater than 20 mm are infrequent so endoscopists have less experience of dealing with them. Increase in size leads to a number of other problems which include: 1) increased complexity of resection; 2) increased duration of resection; 3) difficulty in seeing the far edge; 4) increased bleeding risk due to increased vascularity of larger pedunculated polyps; 5) increased risk of perforation due to diathermy effect delivered to the large flat polyps; 6) increased recurrence rates; and 7) increased risk of malignancy. Due to these challenges and concerns, many patients with large polyps are referred for surgery or to an expert endoscopist.

 

 

giant polyp

Video Endoscopic Sequence 7 of 20.

More fragments are cut

 

giant polyp colon

Video Endoscopic Sequence 8 of 20.

Despite multiple fragments that have been cut, at this moment still need to finish in order of devastate this mass.

More than one-third of the circumference

The greater the circumferential spread of a polyp, the more difficult it is to remove it . As a general rule, a polyp which involves more than one-third of the circumference of the colon wall is difficult to remove endoscopically. It is possible for polyps of this size to be removed by an expert endoscopist using multipiece endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) techniques but these procedures are technically challenging.

 

giant polyp

Video Endoscopic Sequence 9 of 20.

Despite having multiple fragments cut it is still necessary to continue with this procedure.

 

giant polyp

Video Endoscopic Sequence 10 of 20.

Continuing the endoscopic resection of this large mass

 

giant polyp colon

Video Endoscopic Sequence 11 of 20.

Width pedicle, which previously was not possible to visualize

giant polyp

Video Endoscopic Sequence 12 of 20.

Continuing with endoscopic polypectomy with loop diathermy

 

giant polyp

Video Endoscopic Sequence 13 of 20.

In this video clip and the endoscopic image there are little tissue that still need to remove it, to reach its pedicle.

 

 

giant polyp

Video Endoscopic Sequence 14 of 20.

A large fragment is extracted with dormia basket

 

Chicken skin mucosa

Video Endoscopic Sequence 15 of 20.

Chicken skin mucosa

Surrounding the base where the tumor was extracted there is a Chicken skin mucosa

Chicken skin mucosa (CSM), surrounding colorectal adenoma, is an endoscopic finding with pale yellow-speckled mucosa; however, its clinical significance is unknown.

We have almost removed but still there is a polyp tissue

giant polyp

Video Endoscopic Sequence 16 of 20.

The base of the pedicle is observed

 

giant polyp

Video Endoscopic Sequence 17 of 20.

The latter fragment which contains the mark which was cauterized noted, was the basis of the tumor, we proceed to remove it with dormia basket.

 

giant polyp

Video Endoscopic Sequence 18 of 20.

The base of the pedicle is observed.

 

 

giant polyp

Video Endoscopic Sequence 19 of 20.

The argon plasma is used to coagulate the base and prevent recurrence.

 

giant polyp

Video Endoscopic Sequence 20 of 20.

Final status of endoscopic tumor resection of the rectosigmoid junction.

Video Colonoscopic Polypectomy.

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 Colonoscopic view of Colonic Polypectomy

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 Colonoscopic view of Colonic Polypectomy

Video Endoscopic Sequence 3 of 29.

Video Colonoscopic view of Colonic Polypectomy

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.

Endoscopic View of A large and wide pedicle Polyp

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.

Endoscopic View of A large and wide pedicle Polyp

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 Colonoscopic view of Colonic Polypectomy

Video Endoscopic Sequence 6 of 29.

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

giant polyp

Video Endoscopic Sequence 7 of 29.

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

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

Video Endoscopic Sequence 8 of 29.

Note that the tumor has been changed the color

giant polyp

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.

giant polyp

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.

Colonoscopic Snare Polypectomy

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 Colonoscopic view of Colonic Polypectomy

Video Endoscopic Sequence 12 of 29.

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

giant polyp

Video Endoscopic Sequence 13 of 29.

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

giant polyp

Video Endoscopic Sequence 14 of 29.

giant polyp

Video Endoscopic Sequence 15 of 29.

Being removed with a snare around its large stalk.

giant polyp

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.

giant polyp

Video Endoscopic Sequence 17 of 29.

giant polyp

Video Endoscopic Sequence 18 of 29.

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

giant polyp

Video Endoscopic Sequence 19 of 29.

Macroscopic image of the specimen.

giant polyp

Video Endoscopic Sequence 20 of 29.

Note the large and multilobulated tumor

giant polyp

Video Endoscopic Sequence 21 of 29.

Now the other side of the Tumor.

giant polyp

Video Endoscopic Sequence 22 of 29.

giant polyp

Video Endoscopic Sequence 23 of 29.

giant polyp

Video Endoscopic Sequence 24 of 29.

Polyp with a sessil pedicle

giant polyp

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 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 biopsiesby 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 o 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

 

 

 

 

 

 

 

 

 

 

 

 

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