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:
A 60 year old woman with type 2 diabetes and hypertension was found to be FIT+ve under the UK Bowel Cancer Screening Programme. The index colonoscopy, performed by a colleague 2 weeks ago, showed 4 polyps in the sigmoid / rectosigmoid colon. The three smaller polyps (6-15mm diameter) were removed (tubular adenoma, low grade dysplasia). The largest polyp, a 5cm LST-G on a fold at the rectosigmoid junction was left behind for another day. The LST-G was not biopsied. The patient now attends for a further procedure to remove the LST-G (see video…).
The video highlights several tips:
Sigmoid snare polypectomy in spastic, tight sigmoid. Teaching points include:
Small polyp on thick stalk for snare polypectomy at the recto-sigmoid junction cocked up!
Teaching points include:
EMR of a 20mm sigmoid polyp. Main teaching points includes: