LAUSR

The management of pedunculated polyps can be challenging due to the bleeding risk and the technical difficulty in positioning the snare. In cases of a head diameter > 20mm and/or stalk width >10mm, prevention of bleeding is necessary by injection of diluted adrenalin and/or mechanical hemostatic prevention, as recommended by the European Society of Gastrointestinal Endoscopy [1]. Mechanical prevention can hamper resection by causing difficulties in snare opening and placement. In addition to size, the nature of the polyp also influences the bleeding risk, and hamartomatous/juvenile polyps have a higher propensity to bleed [2]. We report here the case of a 60-year-old patient, in whom a large pedunculated polyp of the right colon was discovered during a screening colonoscopy (▶Video 1). During endoscopic characterization, the appearance did not indicate an adenomatous origin; rather, it suggested a hamartomatous/juvenile type (▶Fig. 1). As snaring was difficult due to the large size of the polyp head, we performed resection by endoscopic submucosal dissection (ESD). In the first step, a clip with a rubber band was placed under the head of the polyp to limit bleeding and to allow traction (▶Fig. 2) [3]. Next, a second clip was placed at the base of the stalk. Dissection without injection was then performed between the two clips, which enabled safe resection, aided by traction, and minimized bleeding (▶Fig. 3). Histological analysis confirmed that this was a nondysplastic juvenile polyp with complete resection. ESD could be an interesting alternative for the resection of pedunculated polyps with a large head because the technique overcomes the difficulty in snare positioning following the application of preventive hemostasis methods (such as an endoloop) or caused by the large size of the polyp head.