​Highlighting some key points, Tips/Tricks when considering endoscopic resection of polyps invading diverticula


1. More often the polyp just invades partially superficially into the diverticula, making it easy to tease it out during endoscopic resection
2. For most such polyps conventional EMR should be enough- Ensure that the lifting is in the right plane starting lift away from diverticula gradually moving towards.
3. There is a risk of perforation as no muscularis propria in diverticula
4. Clear cap always helps for any complex resection
5. There is often poor lifting of polyp around the diverticula
6. When resecting the polyp tissue within the diverticula, deflating the lumen and releasing the luminal tension helps
7. Stiff snare (I used medworks flat band snare here) may help get better hold of polyp
8. Underwater resection helps similarly
9. Despite macroscopically complete resection, risk of Recurrent/Residual polyp is high, so always consider site check @ 4-6 month and once again at 18 months
10. Other methods include EFTR, Band ligate and leave (post biopsy) approach or surgery
 

This is a 'difficult polyp because it's almost impossible to get any closer than this.  It's arising from a fold in the ascending colon, just downstream to the caecum.   Keep an eye on that scopeguide image and you see why it's so difficult. 

Of course this makes it difficult to tell how far the polyp extends into the caecal sac.  Fortunately, I was able to get glimpses of just behind the lesion which told me that it didn't extend far beyond the fold.   Had this lesion extended into the 'valley' behind that fold from which its arising, it would have been a 'show stopper' to me. 

Another reason to 'attack' is that the lesion does look benign with 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' (very limited of course) reassurance that the lesion isn't malignant.  

     The main teaching points in the video are: 

• It looks like a benign, sessile TVA and this was subsequently confirmed. 
• The scope stability is an issue and it's difficult to get close to the polyp
• Only a few can cope with >45min procedure and consider GA if you expect the resection to take longer in the right hemicolon 
• On the left side, both you and your patient can take a break every 30-40 minutes . 
• As you work and keep insufflating the ascending colon, the caecum will be pushed further and further away from you - be sparing with the insufflation!
• A local recurrence will happen at that 'blind edge' of your resection
• The muscle propria has taken a hammering and you must absolutely place clips both to reduce the risk of a late perforation but also to reduce the risk of bleeding

Of course, its important to carefully examine the entire stomach especially in premalignant stomach for any synchronous lesions despite seeing something very evident.

The above video is follow up Endoscopy 3 months after the removal of the large sessile lesion in the antrum (photo).  

The polyp was removed by ESD and histology confirmed a Villous adenoma with low and high grade dysplasia as well as a small focus of adenocarcinoma – pT1aM2 (clear margins).

Wisely, it turned out, the patient was recalled for early 'site-check' and examination of the rest of the stomach.   This turned out to be worth while ! 

WHAT DO YOU THINK THE LESION IN THE VIDEO IS?

'Rembacken's Resection Rules' is a 'tongue in cheek' list of General Principles which helps me in my endoscopic practise.   They have stood the test of time !!!