Attack or Abort?
This polyp just distally to the caecum has been referred after an initial set of samples have indicated that it's a benign TVA harbouring no more than LGD. An unfortunate, fixed loop at the hepatic flexure means that I can't retrovert behind this polyp. In fact, it's difficult to get much closer to the lesion than this.
WHAT STATEMENT DO YOU AGREE WITH?
■ The resection may be difficult but it can be done
I agree with that!
■ The location of the lesion and difficult colonic configuration probably makes a resection impossible
Of course the patient may have to travel to a nearby centre with the neccessary expertise!
■ All this is irrelevant as the polyp looks suspicious and would be best removed surgically
I disagree, it does look benign! But will of course have a 15% risk of harbouring cancer...
Actually, the lesion does look very benign. It wobbles about freely perched on top of the first fold distally to the caecum. Furthermore, it has a reassuring gyrate crypt pattern of a TVA. Naturally, any polyp of this size will have a 15% risk of actually containing an unexpected focus of cancer within. Because our therapeutic waiting list is in mess in the aftermath of Covid, I do encourage everyone to sample the sessile lesion even though you are planning to refer it for resection. Such sampling on the surface of large sessile lesions doesn't induce any fibrosis and provides some (limited of course) reassurance that the lesion isn't malignant.
In this case, the position is very challenging but you can get close enough to stand a good chance of removing the lesion. That's actually what I did and I've just uploaded a video of the resection together with my face-to-camera annotation to highlight the main points.
Ultimately, histology confirmed a TVA harbouring no more than LGD