Polypectomy
Huge Mass of the Descending Colon.

Video Endoscopic Sequence 1 of 25.

Huge Mass of the Descending Colon.

A 36 year-old female who presented a history of an interminent rectal bleeding from low to moderate.

A complete colonoscopy is practiced finding an enormous mass in which reveal the first biopsies of the first colonoscopy of being a villius adenoma.

For more endoscopic features download the video clip by clicking on the endoscopic image if you would like to see in full screen, wait to be downloaded the video complete then press Alt and Enter.

 

Polypectomy

All endoscopic images shown in this Atlas contains video clips.

 

 

 

Giant polyp polypectomy

Video Endoscopic Sequence 2 of 25.

Giant polyp polypectomy

Colorectal cancer is one of the most common cancers in developed countries. Increasing numbers of early stage colorectal cancers and precancerous adenomatous lesions, polypoidal type lesions, and flat and depressed type lesions can be visualised and treated endoscopically thanks to endoscopic ultrasonography, high magnification chromoendoscopy and other technical advances.

Polypectomy is generally considered for protuberant lesions, with both sessile and pedunculate morphology, and endoscopic mucosal resection (EMR) is indicated for superficial, flat or depressed types of lesions.

Endoscopic therapy for colonic adenoma with dysplasia and early colorectal cancer is more advantageous than the conventional operative treatment, in that it is a relatively non-invasive and less costly method. However, endoscopic therapy is completely ineffective in lesions with lymph node or distant metastasis.

Therefore, it is becoming more and more important to understand the correct indications and limitations of endoscopic polypectomy/mucosectomy as well as complication rates and the correct follow-up schedule.

 

 

 

Giant polyp polypectomy

Video Endoscopic Sequence 3 of 25.

Giant polyp polypectomy

A week after a follow up endoscopy was performed after the biopsies were confirmed being a tubulous-villous adenoma.

Colonoscopy of Giant polyp polypectomy

Video Endoscopic Sequence 4 of 25.

Colonoscopy of Giant polyp polypectomy

In order to perform hemostasis a solution of adrenaline 1 / 10,000 in a 50% dextrose was inyected, note the color change after this hemostatic maneuver.

Surrounding the base of the tumor a Chicken skin mucosa is shown.

The intent of the injection is to instill saline in the submucosal space directly under the polyp, elevating the mucosa from the muscularis propria layer. A needle is placed into the submucosal space and fluid injected.

The colon wall is extremely thin, varying in thickness from 1.7 to 2.2 mm . Approximately one third of the thickness of the colon wall is composed of mucosa, one third submucosa, and one third muscularis propria.

Injection of fluid into the submucosal layer increases the distance between the mucosa and the outer muscular layer of the bowel wall.

Endoscopic mucosal resection (EMR) in the colon has now come to have the same meaning as "saline-assisted polypectomy" (SAP), or a more recently used term, "submucosal injection polypectomy" (SIP), which more precisely describes the injection technique. Utilizing SIP, it is possible to safely remove both large and small polyps.

 

 

 

Colonoscopy of Giant polyp polypectomy

Video Endoscopic Sequence 5 of 25.

Colonoscopy of Giant polyp polypectomy

The pedicle was rather wide, but after the hemostastic therapy with adrenaline injection, had been a annoying little bleeding in the site of the injection.

Giant Polyp

Video Endoscopic Sequence 6 of 25.

We used argon plasma coagulation to solve this bleeding.

Giant Polyp

Video Endoscopic Sequence 7 of 25.

Endoloop-assisted polypectomy for large pedunculated colorectal polyp.

Use the most large but the mass was so large that they could not be placed as we had hoped.

The use of an endoloop may minimize the risk for bleeding after endoscopic polypectomy of large colorectal polyps.

Giant Polyp

Video Endoscopic Sequence 8 of 25.

It is important to remember that most polyps identified at colonoscopy will never cause the patient harm. In most cases the adenoma-carcinoma sequence progresses slowly.

The endoscopist should therefore always consider the likely natural history of the lesion, the age and co-morbidity of the patient and the risks of the intervention, prior to the procedure.

However, the malignant potential of individual polyps is never known and even small/diminutive polyps can occasionally harbour cancer.

It is therefore advisable that all polyps (even diminutive rectal polyps) should be removed unless they are obviously non-neoplastic.

Polypectomy should not be attempted on a lesion that does not lift following submucosal saline injection.

Non-pedunculated polyps with overt signs of invasion are also best tattooed and biopsied.

Although some specialists are resecting larger and larger mucosal lesions, the endoscopist should only consider removing lesions within their level of experience.

 

 

 

Giant Polyp

Video Endoscopic Sequence 9 of 25.

We decided to place strangling some fragments of the mass.

Giant Polyp

Video Endoscopic Sequence 10 of 25.

Polyps greater than a third of the luminal circumference, those crossing two haustral folds and those involving the base of the appendix or ileo-caecal valve are often best referred for segmental resection or to a specialist endoscopist.

Polyps found in close proximity to colorectal cancers should be documented rather than removed since polypectomy adds an unnecessary risk if the polyp lies within the resection margins of the tumour.

Moreover, some have raised concerns that tumour seeding may occur into recent polypectomy sites and suggest that synchronous polyps be removed after appropriate surgical resection of the tumour.

 

 

 

Giant Polyp

Video Endoscopic Sequence 11 of 25.

In total there were three endoloops placed partially.

Giant Polyp

Video Endoscopic Sequence 12 of 25.

Resected using the piecemeal technique

Because of the large size of this mass the piecemeal technique was used. We use a 50 mm snare that was not enough to fit in this large mass

Most of the fragments were cut with endo cut just the base of the polyp was resected with coagulation

The fractionated cutting mode ENDO CUT I is characterized by alternating cutting and coagulation cycles This makes it possible to carry out controlled cutting with sufficient hemostasis during the entire cutting process, which supports the work of the operating physician.

Giant Polyp

Video Endoscopic Sequence 13 of 25.

It follows with the cut the mass in fragments and still use the endocut.

Large sessile polyps may require piecemeal resection in 1- to 2-cm segments, although if submucosal saline injection is employed, and there is a sufficient saline cushion to prevent thermal damage to the muscularis propria, to remove a larger polyp en bloc to facilitate histologic analysis (particularly in the unanticipated event of a malignant polyp).

Giant Polyp

Video Endoscopic Sequence 14 of 25.

More fragmentation

Giant Polyp

Video Endoscopic Sequence 15 of 25.

More Slices

Remove a larger polyp en bloc to facilitate histologic analysis.

Large sessile polyps may require piecemeal resection in 1- to 2-cm segments, although if submucosal saline injection is employed, and there is a sufficient saline cushion to prevent thermal damage to the muscularis propria, I prefer to remove a larger polyp en bloc to facilitate histologic analysis (particularly in the unanticipated event of a malignant polyp).

Giant Polyp

Video Endoscopic Sequence 16 of 25.

In this fragment was used coagulation instead of endocut so the smoke can be seen.

Giant Polyp

Video Endoscopic Sequence 17 of 25.

This video clips shows resection of the base of the polyp and part of pedicle.

Giant Polyp

Video Endoscopic Sequence 18 of 25.

In this image and the video clip shows that we have almost completed the procedure but there is a small piece of the polyp in which the polypectomy snare was too big and there was a need for a smaller one.

Giant Polyp

Video Endoscopic Sequence 19 of 25.

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.

Giant Polyp

Video Endoscopic Sequence 20 of 25.

With a smaller polypectomy snare it being coagulates the base.

Giant Polyp

Video Endoscopic Sequence 21 of 25.

Polyp Retrieval

Begin to remove the fragment with this basket

Histological examination of the resected specimens is the only reliable way to classify polyps and exclude malignancy and is therefore an essential determinant of the need for further treatment and endoscopic surveillance.

An attempt should therefore always be made to retrieve all resected specimens. Retrieval rates should exceed 90% and should be audited regularly.

Giant Polyp

Video Endoscopic Sequence 22 of 25.

Recover some pieces to be sent to pathology.

Small polyps are readily retrieved through the suction/biopsy channel of the endoscope and are collected either in gauze or mesh between the suction port and the suction tubing or in an in-line suction trap.

Most polyps remain at the site of injection or fall into the nearest dependent pool. If this is not readily apparent, injecting a small bolus of water and following it through will often lead to the pool and suctioning of the fluid will often retrieve the polyp. Changing patient position may also sometimes reveal a lost polyp.

Polyps are often soft and deformable allowing retrieval of lesions much larger than the diameter of the suction/biopsy channel.

If the polyp impacts in the channel at the tip of the endoscope, the channel should be flushed and an alternative retrieval method employed.

Larger polyps >1 cm may not pass through the suction/biopsy channel but may be suctioned onto the tip and withdrawn with the colonoscope.

However, when using this technique, the polyp is readily dislodged during withdrawal and the view is often so limited that the colon distal to the polyp has to be re-examined.

 

 

 

Giant Polyp

Video Endoscopic Sequence 23 of 25.

Final status of endoscopic resection

A follow up colonoscopy was performed in one year a finding a small scar showing only a small white spot

Endoscopic polypectomy of large polyps is safe and can completely replace surgical treatment.

The two major complications are bleeding and perforation, with an incidence of 0.2 to 3%.

Giant Polyp

Video Endoscopic Sequence 24 of 25.

Image of the fragments that were recovered

Giant Polyp

Video Endoscopic Sequence 25 of 25.

Another image of the fragments

Giant Tubulo-Villous Adenoma

Video Endoscopic Sequence 1 of 17.

Giant Tubulo-Villous Adenoma

This is the case of a lady of 60 year-old. Eleven years prior had undergone surgery due to a adenocarcinoma of the sigmoid her sister also had colonic cancer

Colonoscopy shows the anastomosis and pseudodiverticulum scarring due to surgery, the endoscopic anatomy is altered, the location of this tumor can be the anastomosis of the descending colon with the rectum, as we have no data on the surgery.

 

Giant Tubulo-Villous Adenoma

Multilobular Tubulo-Villous Adenoma of the ascending colon limited to the cecum.

Video Endoscopic Sequence 2 of 17.

Multilobular Tubulo-Villous Adenoma of the ascending colon limited to the cecum.

Our patient has another polyp the which was not included in our plan to practice polypectomy and the giant polyp was diagnosed elsewhere and would be subjected to surgery but the patient had requested another opinion with us.

Endoscopic polypectomy of the polyp in the ascending colon.

Video Endoscopic Sequence 3 of 17.

Endoscopic polypectomy of the polyp in the ascending colon.

Giant Polyp

Video Endoscopic Sequence 4 of 17.

Piecemeal Resection.

It was no necessary to inject anything, just fragmented with the diathermy loop. To the small remaining fragments, ablative therapy with argon plasma coagulator

Giant Polyp

Video Endoscopic Sequence 5 of 17.

Fragmented polyp is observed

Giant Polyp

Video Endoscopic Sequence 6 of 17.

The remaining fragments were applied ablative therapy with argon plasma coagulator.

Giant Polyp

Video Endoscopic Sequence 7 of 17.

Started the polypectomy of the left colon tumor

Giant Polyp

Video Endoscopic Sequence 8 of 17.

Injecting a solution of dextrose 50% with epinephrine 1:100,000 (because of patient suffer from arterial hypertension otherwise we injected the 1/10.000).

The injection of fluid into the submucosal layer facilitates safer and easier removal of sessile polyps.

The fluid lifts the polyp and increases the distance between the base of the polyp and the muscularis propria and serosa. This submucosal "cushion" of fluid has been shown to prevent deeper thermal injury during polypectomy.

Giant Polyp

Video Endoscopic Sequence 9 of 17.

With the diathermy loop of 50 mm, started the endoscopic polypectomy, cautery use with "Endocut"

Giant Polyp

Video Endoscopic Sequence 10 of 17.

This video clip shows the tumor has been fragmented into two fragments.

Giant Polyp

Video Endoscopic Sequence 11 of 17.

At first we had thought that a blood vessel would be active but we realized that it was just residual blood.

Giant Polyp

Video Endoscopic Sequence 12 of 17.

This video clip shows removal of the large fragment

Giant Polyp

Video Endoscopic Sequence 13 of 17.

It fragmented into small pieces

Giant Polyp

Video Endoscopic Sequence 14 of 17.

The residual fragments is also trying to cut.

Giant Polyp

Video Endoscopic Sequence 15 of 17.

Ablative therapy with argon plasma coagulation to base of the tumor was apply.

Giant Polyp

Video Endoscopic Sequence 16 of 17.

35 day after

A follow up endoscopy was performed observing the scar of the previous polypectomy of the polips in the ascendig colon.

Giant Polyp

Video Endoscopic Sequence 17 of 17.

35 day after

The scar of the polypectomy of giant polyp in the left colon

Tubulo-Villous Adenoma.

Video Endoscopic Sequence 1 of 28.

Tubulo-Villous Adenoma.

An 81 year-old female that was suffering anemia and was referred to us for colonoscopic evaluation, Four polyps were found, two at the rectum and two at the sigmoid, as well as multiple diverticulae.

Adenomatous polyps are, by definition, neoplastic.
Although benign, they are the direct precursors of adenocarcinomas and follow a predictable cancerous temporal course unless interrupted by treatment. They can be either pedunculated or sessile.

Adenomas are divided into 3 subtypes based on histologic criteria, (1) tubular, (2) tubulovillous, and (3) villous. According to World Health Organization (WHO) criteria, villous adenomas are composed of greater than 80% villous architecture. Tubular adenomas are encountered most frequently (80-86%).

Tubulovillous adenomas are encountered less frequently (8-16%), and villous adenomas are encountered least frequently (5%).

 

 

 

Tubulo-Villous Adenoma.

Video Endoscopic Sequence 2 of 28.

The patient finally decided, five months later, to be treated by the polypectomy procedure. Between both pictures, the previous one and the later, the later macroscopic image displays many changes. It is very likely that abnormal macroscopic growth will occur in five months.

Tubulo-Villous Adenoma.

Video Endoscopic Sequence 3 of 28.

We have to decide between a convencional picemeal polypectomy or a mucosectomy EMR endoscopic mucosal resection.

Tubulo-Villous Adenoma.

Video Endoscopic Sequence 4 of 28.

Therapeutic Intervention.

The image and the video clip display a pedunculated polyp seen at the sigmoid, an endoloop that is being placed throughout the working channel of the scope.
The endoloop was fixed and cut the pedicle of the polyp.

Colon Polyp

Video Endoscopic Sequence 5 of 28.

The image and the video clip display the endoop being applied to the pedicle which has been tightened around the stalk of the polyp.

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.

Colon Polyp

Video Endoscopic Sequence 6 of 28.

More pressure is exerted by the handle of endoloop.

Colon Polyp

Video Endoscopic Sequence 7 of 28.

It is observed in the video the loosening of the polyp that was cut with the handle of the endoloop. The purpose was not the cutting but to perform the hemostasis.

Colon Polyp

Video Endoscopic Sequence 8 of 28.

The argon catheter is observed, stopping a small bleeding.

Colon Polyp

Video Endoscopic Sequence 9 of 28.

The image and the video display the final status of the first polypectomy.

Colon Polyp

Video Endoscopic Sequence 10 of 28.

The next polyp is also in the sigmoid, but a little more difficult to snare, since it is located on the curvature, after the recto-sigmoid junction and there are several diverticulae nearby.

Colonic chicken skin mucosa

Video Endoscopic Sequence 11 of 28.

The pedicle is observed with mucosa in chicken skin

Colonic chicken skin mucosa is an endoscopic entity that occurs as a result of fat accumulation in macrophages in the lamina propria of the mucosa adjacent to colonic neoplasms. Small intestine-like microvilli were present in CSM and the pathophysiological implications remain to be elucidated.


Colonic chicken skin mucosa: an endoscopic and histological abnormality adjacent to colonic neoplasms

At first, we thought to place an endoloop on the pedicle, but afterwards we decided to use argon plasma coagulator, aiming at the reduction of its size, and then cautery will be applied to the wire loop to tight around the stalk of the polyp.

Colon Polyp

Video Endoscopic Sequence 12 of 28.

We began the procedure by using the Argon Plasma Coagulator.

Colon Polyp

Video Endoscopic Sequence 13 of 28.

The image and the video clip display the effectiveness of the Argon Plasma Coagulator, reducing the size of the polyp and excisioning it afterwards.

Colon Polyp

Video Endoscopic Sequence 14 of 28.

More therapeutic action using APC.

Colon Polyp

Video Endoscopic Sequence 15 of 28.

For more endoscopic details download the video clips.

Colon Polyp

Video Endoscopic Sequence 16 of 28.

Status post Argon Plasma Coagulator.
At this moment we decided to put aside this procedure, with the purpose of taking it back in a second instance.

The size reduction will be easier, doing the extraction with the diatermia snare. At this moment we decided to cut both polyps of the rectum, the big and the small one.

Colon Polyp

Video Endoscopic Sequence 17 of 28.

After one hour and twenty minutes, we continued the polypectomy of the remnant with snare excision.
The goal to reduce it of size with APC has been fulfilled.

Colon Polyp

Video Endoscopic Sequence 18 of 28.

After reducing the size of the polyp using argon plasma coagulator (APC). Cautery is applied to the wire loop which has been tightened around the stalk of the polyp.

Colon Polyp

Video Endoscopic Sequence 19 of 28.

Piecemeal excision of the rectal adenoma.

The image and the video clips display the procedure, that carried out with piecemeal excision. Large sessile polyps usually require piecemeal snare resection.

Colon Polyp

Video Endoscopic Sequence 20 of 28.

Placement of a snare wire over the head of the polyp. Cautery is applied to the wire loop which has been tightened around the stalk of the polyp.

Colon Polyp

Video Endoscopic Sequence 21 of 28.

The fragment of the polyps have fallen out.
They are showed here, after the removal of the first fragment.

Colon Polyp

Video Endoscopic Sequence 22 of 28.

 In this image and the video clip, is observed the biggest
 fragment of the polyps that has been excisioned.

Colon Polyp

Video Endoscopic Sequence 23 of 28.

More tissue is being excisioned with the diatermia snare.

Colon Polyp

Video Endoscopic Sequence 24 of 28.

The fragment that has been cut is observed.
Excised polyp, waiting to be retrieved.

Colon Polyp

Video Endoscopic Sequence 25 of 28.

A tiny rectal polyp has been excicioned.

Colon Polyp

Video Endoscopic Sequence 26 of 28.

The polyp is excised piecemeal using a snare.
The image and the video clip display a fragment that has been cutting from the adenoma.

Colon Polyp

Video Endoscopic Sequence 27 of 28.

Status post endoscopic polypectomy after the adenoma was performed with piecemeal snare resection.

Colon Polyp

Video Endoscopic Sequence 28 of 28.

Another image and video clip of the status post endoscopic polypectomy.

The entire colon must be examined during the polypectomy so that any synchronous lesions can be detected and removed.

Approximately 50% of patients will have a second adenomatous polyp at the time of initial colonoscopy, while metachronous polyps are found in 20-50% of patients within five years of the initial polypectomy.

If follow-up colonoscopy verifies that no residual polyps exist, colonoscopy should be repeated within three years and thereafter every five years.

 

 

 

colon polyp

Video Endoscopic Sequence 1 of 11.

Endoscopic Resection of tubulo-villous adenoma

A 67-year-old female, who in a routine colonoscopy was detected this "carpeted" flat polyp near the appendix hole.

 

 

cecum polyp

Video Endoscopic Sequence 2 of 11.

One week later, after having the results of the biopsies, endoresection of this neo-formation was carry out.

 

 

Colonic Polyp

Video Endoscopic Sequence 3 of 11.

Adrenaline with saline solution is infiltrated at 1/10.000



polyp polypectomy

Video Endoscopic Sequence 4 of 11.

Endoresection with a diathermy loop is performed resecting some fragments.

 

 

 

Colon Polyp

Video Endoscopic Sequence 5 of 11.

The procedure is followed by infiltrating more solution and resecting more fragments.

Video Endoscopic Sequence 6 of 11.

 

Polipo Colon

Video Endoscopic Sequence 7 of 11.

 

Colon Polyps

Video Endoscopic Sequence 8 of 11.

The catheter of argon plasma coagulator is observed and used to exert ablative therapy on small fragments.

 

Polipectomia Endoscopica

Video Endoscopic Sequence 9 of 11.

In the image as well as video clip shows, the first hemoclip that is placed.

 

Endoscopic Polypectomy

Video Endoscopic Sequence 10 of 11.

The second hemoclip.

 

Endoscopic Polypectomy

Video Endoscopic Sequence 11 of 11.

Final Status of of Endo Resection. The pacient is scheduled for a new follow-up colonoscopy.

Three hemoclips of 16 mm of opening are applied.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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