Post written by Michael Lajin, MD, from Sharp HealthCare, San Diego, California, USA.
An 87-year-old woman with multiple comorbidities was found to have a gigantic gastric polyp (11 × 8 cm) with a broad short stalk containing an area of irregular vascular patterns worrisome for high-grade dysplasia. Attempting polypectomy using an endoloop was challenging because of the size.
As a result of the suspicion of high-grade dysplasia, the lesion was removed en bloc with endoscopic submucosal dissection (ESD) assisted by a novel retraction device (Tracmotion; Fujifilm, Tokyo, Japan).
Using this device, we exposed different aspects of the stalk, allowing submucosal injection before a near-circumferential mucosal incision at the stalk. Submucosal dissection was then performed. Encountered blood vessels were coagulated.
After completing submucosal dissection, the remaining mucosal bridge was cut. The lesion was resected en bloc without adverse events. However, the large size of the lesion was prohibitive for en bloc retrieval.
The lesion was fragmented and retrieved one piece at a time. The ESD defect was closed with clips. Despite fragmentation, retrieval resulted in a deep tear at the level of the upper esophageal sphincter, resulting in subcutaneous emphysema without clinical features of mediastinitis.
The patient was managed conservatively with parenteral antibiotics, bowel rest, and parenteral nutrition. No surgery was required. The subcutaneous emphysema resolved after 72 hours. An esophagram performed after 2 weeks showed complete healing.
The final pathology was adenoma with high-grade dysplasia and intramucosal cancer. The margins of the high-grade dysplasia were clear. No invasion of the polyp stalk or submucosa was identified in any of the fragments. Follow-up endoscopy after 4 months showed a scar without evidence of residual adenoma or malignancy.
This case demonstrates that careful inspection and characterization of large adenomatous gastric polyps are vital in determining the best resection plan. ESD enables en bloc endoscopic resection of gigantic gastric polyps with broad and short stalks. In this setting, the Tracmotion retraction device can be used to expose the different sides of the stalk in order to facilitate circumferential mucosal incision.
Because the stalk is the most important piece for histological evaluation, one possibility of retrieving this large gastric lesion after en bloc resection is to incise and retrieve the entire stalk in one piece and then fragment the rest of the lesion into smaller easily retrievable fragments.
Endoscopic image of the large adenomatous gastric polyp.
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