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Endoloop-Assisted Polypectomy Technique
Endoloop-Assisted Polypectomy Technique M Singh and A Rastogi, Veterans Affairs Medical Center, Kansas City, MO, USA, and University of Kansas, Kansas City, KS, USA r 2013 Elsevier GmbH. All rights reserved. Received 7 May 2012; Revision submitted 7 May 2012; Accepted 11 May 2012
Abstract Endoscopic resection of large pedunculated colon polyps should be preferred over surgical resection; however, it carries the risk of associated significant postpolypectomy bleeding. With advances in endoscopic tools such as endoclips and endoloops, it has become safer to perform endoscopic resection of large pedunculated polyps. Herein are demonstrated some important aspects of the technique for endoscopic resection of a large pedunculated colon polyp. This article is part of an expert video encyclopedia.
Keywords Endoloop; Endoscopic resection; Pedunculated colon polyp; Standard endoscopy; Video.
Video Related to this Article Video available to view or download at doi:10.1016/S22120971(13)70141-9
Materials
• • •
Colonoscope: CF H180AL (Olympus America, Inc., Center Valley, PA, USA). Snare: AcuSnare Polypectomy Snare 1.5 cm 3 cm (Cook Medical, Bloomington, IN, USA). Single-use ligating device: Polyloop (Olympus America, Inc.).
Background and Endoscopic Procedure Colon cancer-related mortality has been on the decline with use of colonoscopy with polypectomy.1 Most colon polyps are small (o1 cm) and can be safely removed by simple endoscopic techniques. Either surgical or endoscopic resection can be performed for removal of large pedunculated colon polyps depending on the size, morphology, and location of such polyps. Surgical approach involves segmental resection of part of the colon, whereas endoscopic resection is less invasive and should be preferred. However, it can be technically challenging for the endoscopist, especially for polyps 420 mm with a thick stalk or those located in difficult location2 because of the risk of excessive postpolypectomy bleeding.3 Endoscopic resection of large and pedunculated polyps has become more feasible with advances in endoscopy equipment, imaging, and utilization of techniques such as endoclip- or endoloop-assisted polypectomy4,5 in the hands of expert endoscopists. Using an index case, this video demonstrates the techniques of endoloop-assisted endoscopic resection of a large This article is part of an expert video encyclopedia. Click here for the full Table of Contents.
Video Journal and Encyclopedia of GI Endoscopy
pedunculated colon polyp. A 58-year-old Caucasian male underwent a screening colonoscopy and was found to have a 2.5-cm pedunculated polyp in the rectosigmoid region. The pedunculated polyp had a thick pedicle that usually has a feeding vessel and therefore has a high potential for postpolypectomy bleeding. To prevent excessive bleeding, a loop ligating device like an endoloop (Polyloop; Olympus America, Inc.) can be deployed around the pedicle to act as a tourniquet to prevent bleeding after the polyp is removed. The technique of deploying an endoloop involves opening the loop, then maneuvering it around the polyp, and bringing it down to the level of the pedicle. This deployment of the endoloop can be challenging sometimes, as the endoloop is floppy and not as stiff as a snare. Also, it is important to position the endoloop on the stalk at some distance away from the lower edge of the polyp so that polypectomy can be performed above the endoloop. After securing the endoloop in good position around the pedicle, it is tightened and then released from the sheath. The tightened endoloop around the stalk acts like a tourniquet, tamponading the vessel in the pedicle. The snare is then manipulated around the polyp and tightened around the stalk, above the closed endoloop, and snare cautery polypectomy is performed. After polypectomy, the endoloop should still be securely tight around the remaining pedicle. The prophylactic use of endoloop-assisted endoscopic resection of a large pedunculated polyp can prevent postpolypectomy bleeding; in this case there was no bleeding after the polyp was resected. The histopathology of the polyp showed tubulovillous adenoma and a clear stalk margin.
Key Learning Points/Tips and Tricks
• • •
Use of endoloop-assisted polypectomy of large pedunculated polyp prevents postpolypectomy bleeding. The position of the endoloop on the stalk should be at some distance from the lower edge of the polyp so that polypectomy can be performed above the endoloop. The tightened endoloop around the stalk acts like a tourniquet, thereby tamponading the vessel in the pedicle.
http://dx.doi.org/10.1016/S2212-0971(13)70141-9
323
324 Endoloop-Assisted Polypectomy Technique
•
The correct positioning of the endoloop with polypectomy leads to clear stalk margin.
00:52–01:08
After endoloop is in a good position it is tightened and then released. The tightened endoloop tamponades the vessel in pedicle.
01:12–01:32
A snare is passed and manipulated to bring it down over the polyp stalk.
01:33–01:41
The snare is then tightened above the endoloop and polypectomy performed.
01:42–01:48
After polypectomy, the endoloop is still tightly secured.
01: 49–end
This patient did well and did not have any post polypectomy bleeding. The histopathology of the polyp showed tubulovillous adenoma and a clear stalk margin.
Complications and Risk Factors
• • •
Immediate and delayed postpolypectomy bleeding. Colonic perforation. Postpolypectomy syndrome.
Alternatives to the Procedure
• •
Endoscopic surveillance without removing the polyp. Surgical resection.
References Scripted Voiceover Time (min:sec)
Voiceover script
00:00–00:15
This video shows a 2.5 cm pedunculated polyp in the rectosigmoid that has a thick pedicle which usually has a feeding vessel.
00:16–00:23
To prevent bleeding we apply a loop ligating device like endoloop that acts as a tourniquet.
00:24–00:40
Here you see that the endoloop is opened and negotiated around the polyp and brought down to the pedicle.
00:41–00:51
Endoloop is positioned on the stalk some distance away from the lower edge of polyp.
1. Zauber, A. G.; Winawer, S. J.; O’Brien, M. J.; et al. Colonoscopic Polypectomy and Long-Term Prevention of Colorectal-Cancer Deaths. N. Engl. J. Med. 2012, 366(8), 687–696. 2. Tanaka, S.; Haruma, K.; Oka, S.; et al. Clinicopathologic Features and Endoscopic Treatment of Superficially Spreading Colorectal Neoplasms Larger than 20 mm. Gastrointest. Endosc. 2001, 54, 62–66. 3. Kouklakis, G.; Mpoumponaris, A.; Gatopoulou, A.; et al. Endoscopic Resection of Large Pedunculated Colonic Polyps and Risk of Postpolypectomy Bleeding with Adrenaline Injection Versus Endoloop and Hemoclip: A Prospective, Randomized Study. Surg. Endosc. 2009, 23(12), 2732–2737. 4. Luigiano, C.; Ferrara, F.; Ghersi, S.; et al. Endoclip-Assisted Resection of Large Pedunculated Colorectal Polyps: Technical Aspects and Outcome. Dig. Dis. Sci. 2010, 55(6), 1726–1731. 5. Mizukami, T.; Hiroyuki, I.; Hibi, T. Anchor Clip Technique Helps in Easy Prevention of Post-Polypectomy Hemorrhage of Large Colonic Polyps. Dig. Endosc. 2010, 22(4), 366–369.
Abstract Endoscopic resection of large pedunculated colon polyps should be preferred over surgical resection; however, it carries the risk of associated significant postpolypectomy bleeding. With advances in endoscopic tools such as endoclips and endoloops, it has become safer to perform endoscopic resection of large pedunculated polyps. Herein are demonstrated some important aspects of the technique for endoscopic resection of a large pedunculated colon polyp. This article is part of an expert video encyclopedia.
Keywords Endoloop; Endoscopic resection; Pedunculated colon polyp; Standard endoscopy; Video.
Video Related to this Article Video available to view or download at doi:10.1016/S22120971(13)70141-9
Materials
• • •
Colonoscope: CF H180AL (Olympus America, Inc., Center Valley, PA, USA). Snare: AcuSnare Polypectomy Snare 1.5 cm 3 cm (Cook Medical, Bloomington, IN, USA). Single-use ligating device: Polyloop (Olympus America, Inc.).
Background and Endoscopic Procedure Colon cancer-related mortality has been on the decline with use of colonoscopy with polypectomy.1 Most colon polyps are small (o1 cm) and can be safely removed by simple endoscopic techniques. Either surgical or endoscopic resection can be performed for removal of large pedunculated colon polyps depending on the size, morphology, and location of such polyps. Surgical approach involves segmental resection of part of the colon, whereas endoscopic resection is less invasive and should be preferred. However, it can be technically challenging for the endoscopist, especially for polyps 420 mm with a thick stalk or those located in difficult location2 because of the risk of excessive postpolypectomy bleeding.3 Endoscopic resection of large and pedunculated polyps has become more feasible with advances in endoscopy equipment, imaging, and utilization of techniques such as endoclip- or endoloop-assisted polypectomy4,5 in the hands of expert endoscopists. Using an index case, this video demonstrates the techniques of endoloop-assisted endoscopic resection of a large This article is part of an expert video encyclopedia. Click here for the full Table of Contents.
Video Journal and Encyclopedia of GI Endoscopy
pedunculated colon polyp. A 58-year-old Caucasian male underwent a screening colonoscopy and was found to have a 2.5-cm pedunculated polyp in the rectosigmoid region. The pedunculated polyp had a thick pedicle that usually has a feeding vessel and therefore has a high potential for postpolypectomy bleeding. To prevent excessive bleeding, a loop ligating device like an endoloop (Polyloop; Olympus America, Inc.) can be deployed around the pedicle to act as a tourniquet to prevent bleeding after the polyp is removed. The technique of deploying an endoloop involves opening the loop, then maneuvering it around the polyp, and bringing it down to the level of the pedicle. This deployment of the endoloop can be challenging sometimes, as the endoloop is floppy and not as stiff as a snare. Also, it is important to position the endoloop on the stalk at some distance away from the lower edge of the polyp so that polypectomy can be performed above the endoloop. After securing the endoloop in good position around the pedicle, it is tightened and then released from the sheath. The tightened endoloop around the stalk acts like a tourniquet, tamponading the vessel in the pedicle. The snare is then manipulated around the polyp and tightened around the stalk, above the closed endoloop, and snare cautery polypectomy is performed. After polypectomy, the endoloop should still be securely tight around the remaining pedicle. The prophylactic use of endoloop-assisted endoscopic resection of a large pedunculated polyp can prevent postpolypectomy bleeding; in this case there was no bleeding after the polyp was resected. The histopathology of the polyp showed tubulovillous adenoma and a clear stalk margin.
Key Learning Points/Tips and Tricks
• • •
Use of endoloop-assisted polypectomy of large pedunculated polyp prevents postpolypectomy bleeding. The position of the endoloop on the stalk should be at some distance from the lower edge of the polyp so that polypectomy can be performed above the endoloop. The tightened endoloop around the stalk acts like a tourniquet, thereby tamponading the vessel in the pedicle.
http://dx.doi.org/10.1016/S2212-0971(13)70141-9
323
324 Endoloop-Assisted Polypectomy Technique
•
The correct positioning of the endoloop with polypectomy leads to clear stalk margin.
00:52–01:08
After endoloop is in a good position it is tightened and then released. The tightened endoloop tamponades the vessel in pedicle.
01:12–01:32
A snare is passed and manipulated to bring it down over the polyp stalk.
01:33–01:41
The snare is then tightened above the endoloop and polypectomy performed.
01:42–01:48
After polypectomy, the endoloop is still tightly secured.
01: 49–end
This patient did well and did not have any post polypectomy bleeding. The histopathology of the polyp showed tubulovillous adenoma and a clear stalk margin.
Complications and Risk Factors
• • •
Immediate and delayed postpolypectomy bleeding. Colonic perforation. Postpolypectomy syndrome.
Alternatives to the Procedure
• •
Endoscopic surveillance without removing the polyp. Surgical resection.
References Scripted Voiceover Time (min:sec)
Voiceover script
00:00–00:15
This video shows a 2.5 cm pedunculated polyp in the rectosigmoid that has a thick pedicle which usually has a feeding vessel.
00:16–00:23
To prevent bleeding we apply a loop ligating device like endoloop that acts as a tourniquet.
00:24–00:40
Here you see that the endoloop is opened and negotiated around the polyp and brought down to the pedicle.
00:41–00:51
Endoloop is positioned on the stalk some distance away from the lower edge of polyp.
1. Zauber, A. G.; Winawer, S. J.; O’Brien, M. J.; et al. Colonoscopic Polypectomy and Long-Term Prevention of Colorectal-Cancer Deaths. N. Engl. J. Med. 2012, 366(8), 687–696. 2. Tanaka, S.; Haruma, K.; Oka, S.; et al. Clinicopathologic Features and Endoscopic Treatment of Superficially Spreading Colorectal Neoplasms Larger than 20 mm. Gastrointest. Endosc. 2001, 54, 62–66. 3. Kouklakis, G.; Mpoumponaris, A.; Gatopoulou, A.; et al. Endoscopic Resection of Large Pedunculated Colonic Polyps and Risk of Postpolypectomy Bleeding with Adrenaline Injection Versus Endoloop and Hemoclip: A Prospective, Randomized Study. Surg. Endosc. 2009, 23(12), 2732–2737. 4. Luigiano, C.; Ferrara, F.; Ghersi, S.; et al. Endoclip-Assisted Resection of Large Pedunculated Colorectal Polyps: Technical Aspects and Outcome. Dig. Dis. Sci. 2010, 55(6), 1726–1731. 5. Mizukami, T.; Hiroyuki, I.; Hibi, T. Anchor Clip Technique Helps in Easy Prevention of Post-Polypectomy Hemorrhage of Large Colonic Polyps. Dig. Endosc. 2010, 22(4), 366–369.