Post written by Sukit Pattarajierapan, MD, from the Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

A 60-year-old man presented with intermittent abdominal pain. An abdominal CT scan showed colocolonic intussusception of the sigmoid with a 50-mm polypoid mass as the leading point. We performed a colonoscopy and found a giant pedunculated polyp at the sigmoid colon with a 50-mm head diameter and 20-mm stalk width. Magnifying narrow-band imaging showed a type 2B polyp of Japanese Narrow-Band Imaging Expert Team classification.

Because of the huge size and thick stalk, we applied a detachable snare around the stalk before resection. The detachable snare placement was challenging because of the huge polyp head and floppy loop. We altered the patient’s position to allow gravity to make the polyp head swing into the loop.

Finally, we successfully deployed a detachable snare around the stalk, which was shortened after detachable snare tightening. We used a scissor-type knife (SB Knife Jr.; Sumitomo Bakelite, Tokyo, Japan) to cut the stalk precisely, avoiding incomplete resection and loop detachment.

After successful resection, specimen retrieval was difficult because of the vacuum effect of the large specimen. We used the clip-with-line method to pull the specimen simultaneously with CO₂ insufflation to break the vacuum effect. We retrieved the specimen, and pathologic examination showed a tubulovillous adenoma with high-grade dysplasia and negative all resection margins.

With polypectomy of giant pedunculated polyps such as our case, difficulty occurs during detachable snare placement, resection, and specimen retrieval. We described technical tips to overcome the challenge.

First, alteration of the patient’s position is helpful during detachable snare placement, allowing gravity to swing the polyp head into the loop. Second, the scissor-type knife enables precise dissection in a challenging situation with a shortened stalk after detachable snare tightening. Third, to break the vacuum seal and retrieve the large specimen, we simultaneously pulled the specimen using the clip-with-line method with CO₂ insufflation. 

In conclusion, endoscopic resection of a giant pedunculated polyp using a detachable snare and scissor-type knife is safe and effective.

A, Endoscopic image showing the polyp with a deployed detachable snare around the stalk. The polyp’s color turned deep purple as the result of ischemia, and the stalk was shortened. B, A scissors-type knife was used to cut the stalk precisely, avoiding incomplete resection and loop detachment.

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