Douglas A. Howell, MD, FASGE, from the Maine Medical Center, Interventional Endoscopy, in Portland, Maine, USA shares this VideoGIE case “Combined volume reduction with the loop-and-leave technique permits safe endoscopic management of high-risk giant gastric polyps.”

Giant inflammatory or reactive polyps occur in the upper GI tract. Hyperplastic polyps have a <2% malignant risk. These lesions present with acute and chronic bleeding, pyloric outlet obstruction symptoms or dyspepsia, pain from prolapse, and intussusception. Malignancy can be ruled out by appearance, mobility, and extensive forceps biopsy. Removal for histology is both dangerous and unnecessary in most cases, especially if patients are elderly or high risk. There are many technical challenges limiting endoscopic removal including large lesions that cannot be encircled even with large snares, thick stalks too large for definitive clipping, large feeding arterial vessels, and inaccessible location.

This instructional video showcases a comprehensive, safe, and simple technique for the management of giant benign foregut hyperplastic polyps. Endoscopic removal is accomplished without risking snare resection using the combined techniques of epinephrine injection for volume reduction and endoloop strangulation. Endoscopic follow-up is needed to confirm complete removal and detect a low instance of recurrences.

The video presents 3 very challenging cases of symptomatic large gastric polyps in one elderly woman with severe commodities, a patient with Roux-en-Y bypass, and finally a patient with hemophilia with a 10cm lesion.

The combination of these 2 techniques can be mastered easily and would appear to be safer compared to current treatments. The combination of these 2 techniques can be mastered easily and would appear to be safer compared to current treatments.

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