LAUSR

A 60-year-old man with abdominal discomfort was referred to our hospital. Abdominal computed tomography (CT) revealed a tumor in the hepatic flexure and colonoscopy showed a giant protruding polyp (▶Fig. 1). The biopsies were interpreted as adenoma with areas of high grade dysplasia. Therapeutic endoscopy was performed using scissor-type forceps (Sumitomo Bakelite, Japan) and a RetroView colonoscope (Pentax, Japan) with a distal attachment cap (Olympus, Japan) (▶Video 1). First, we took advantage of the polyp's own weight to exert traction in order to form a pseudo-peduncle (▶Fig. 2). We began cutting the mucosal layer to expose the submucosa. Then, countertraction with a soft straight distal cap facilitated exposure of the dissection plane between the lesion and the muscle layer (▶Fig. 3). We coagulated the larger vessels in advance. At one point, some muscle fibers were identified by means of the muscle-retraction sign [1] (▶Fig. 4). The resection was completed within 70 minutes without adverse events. The endoscopic resection defect was closed with endoscopic clips (Boston Scientific, United States). Pathology examination showed an adenoma 48×35mm in size with low grade dysplasia. Resection margins were clean and included muscle fibers of the main muscle layer (▶Fig. 5). In the 24-month follow-up no residual adenomatous tissue was observed. Unfortunately, most cases of endoscopic resection of complex polyps are limited to a piecemeal technique because of the types of polypectomy snare used [2]. However, we now have fast, easy, and safe endoscopic submucosal dissection (ESD) devices [3], that can help in performing en bloc resection. This case report, similarly to previous ones [4], demonstrates that the scissorstyle knife can safely speed en bloc resection in a western setting. Further studies are needed to assess the efficacy and safety of this device when used in the resection of protruding polyps by nonexpert ESD endoscopists.