Post written by Vivek Kaul, MD, FASGE, from the Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, New York, USA.

We have presented a case of endoscopic resection of a large gastric polyp/mass that was responsible for symptomatic, recurrent, transfusion-dependent iron deficiency anemia and gastrointestinal bleeding in our patient. This patient had suffered from this problem for several years and prior attempts at resection were unsuccessful multiple times before he was referred to our center.

This video and case presentation is important at many levels:

1. This video highlights the importance of a strong clinical indication for endoscopic intervention. This patient had severe symptoms related to this luminal pathology and successful endoscopic intervention enabled complete resolution of the problem using a minimally invasive approach.
2. The technique and principles of endoscopic resection of a large (gigantic) foregut lesion are demonstrated in detail in this video. The importance of complete (en-bloc in this case) resection, control of bleeding, and avoidance of perforation are the various aspects highlighted. The use of an endoscopic loop and various types of commercially available endoclips is also shown.
3. In addition, the technique of retrieval of a large resected specimen per orally is also demonstrated, keeping in mind the risks associated with such a maneuver. The importance of monitoring for significant luminal trauma in the esophagus is emphasized, in case intra-procedural intervention is warranted.
4. Finally, the importance of long-term follow-up and impact of an endoscopic intervention is also highlighted: did the procedure result in a durable overall positive outcome for the patient as envisioned? In our patient it certainly did because he had no further recurrence of bleeding or anemia since the procedure.

Two of the most important things to learn and master in our opinion are case selection and choice of intervention. This is a patient who had a super-large friable inflammatory polyp that had caused him several years of difficulty due to bleeding and anemia, hospital and ED visits, blood transfusions, etc. This is exactly the type of patient that would benefit most from a successful endoscopic intervention.

The other learning points are the technical principles of endoscopic resection of difficult or large lesions and the appropriate use of a variety of devices and accessories as part of that intervention. This is one of the few video reports that demonstrates the use of an endoscopic loop to help facilitate resection of a large foregut lesion. The prophylactic use of endoclips is also shown, along with the meticulous technique of retrieval of a large lesion through the GE junction and tight upper-esophageal sphincter, without causing significant trauma.

We hope that our colleagues will find value in this report and find the tips and techniques shown here useful in their endoscopy practice. We look forward to any questions/comments/suggestions.

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