Successful EMR of large adenoma

Dr. Ryan LawRyan Law, DO from the Department of Gastroenterology and Hepatology at Northwestern University Feinberg School of Medicine in Chicago, Illinois, USA shares this case from the VideoGIE section “Prevention of delayed perforation after resection of a massive lateral wall duodenal polyp by using an anchored, fully-covered self-expandable metal stent.”

This video demonstrates successful endoscopic mucosal resection (EMR) of a large, lateral wall tubulovillous adenoma. The adenoma was lifted using saline-HPMC solution and fully resected with piecemeal snare polypectomy. Following complete resection, APC and coagulation forceps were used to manage minimal bleeding from submucosal vessels. Due to concern for delayed perforation, a fully-covered esophageal self-expandable metal stent (SEMS) was deployed and anchored into position with an over-the-scope clipping device covering the post-resection defect. Repeat endoscopy was performed 7 days later with removal of the stent and anchoring clip. The patient remains clinically well.

This case demonstrates placement of a fully-covered esophageal SEMS for prevention of delayed perforation following deep EMR. Additionally, the duodenal SEMS was anchored into place using a an over-the-scope clipping device to prevent migration.

Though this technique requires further study, it can be considered in certain clinical scenarios with concern for delayed perforation following deep EMR. Endoscopists should be aware that SEMS usage in similar scenarios has theoretical risks, namely duodenal perforation induced by SEMS expansion and obstruction of pancreaticobiliary drainage leading to acute pancreatitis or cholangitis. Neither adverse event was observed in our patient.

Figure 1

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