Case Presentation: Diminutive polyps. Siwan Thomas-Gibson St. Marks Hospital London UK

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1 Case Presentation: Diminutive polyps Siwan Thomas-Gibson St. Marks Hospital London UK

2 Case History 65 year old gentleman Bowel cancer screening FOBT positive No bowel symptoms No family history Smoker

3 Screening Colonoscopy 2009 Scope passed to terminal ileum Excellent bowel preparation Sigmoid diverticulosis Single 6mm pedunculated polyp at recto-sigmoid junction (18cm)

4 1. What would you do next? 1. Direct to cold snare (it s coming off anyway) 2. Direct to hot snare (it s coming off anyway) 3. Carefully inspect polyp head with dyespray/nbi 4. Inject base with EMR solution before resection 5. Place an endo-loop then hot snare

5 3: Carefully inspect polyp head with dyespray/nbi Assume polyp carefully examined Described as Ip adenoma Proceeded with snare polypectomy

6 2. Which snare, how and where to snare? 1. Cold snare base of polyp stalk 2. Hot snare mid-third of polyp stalk 3. Hot snare upper third of polyp stalk 4. Hot snare base of stalk with pre-injection

7 2: Hot snare mid-third of polyp stalk Polyp resected in one piece and retrieved Histology: low grade dysplastic tubular adenoma Specimen fragmented so completeness of excision cannot be assessed Patient discharged from screening

8 2 years later: Positive FOBT Patient re-enters screening programme Asymptomatic Well except two episodes of self-limiting fast Atrial Fibrillation since last colonoscopy Positive FOBT Screening colonoscopy Scope passed to terminal ileum Normal insertion except sigmoid diverticulosis Some liquid stool in lumen in left colon

9 3. What is the best position to examine left colon during extubation? 1. Left lateral 2. Supine 3. Right lateral 4. Prone 5. Whatever position the patient is most comfortable in

10 2: Supine or c: Right lateral Patient moved to right lateral at splenic flexure on extubation Views not perfect so moved supine Polyp stalk seen at 18cm in diverticular segment Assumed residual stalk from previous polypectomy Stalk seen but unable to determine if any residual dysplastic tissue (difficult views due to Div Disease) Reviewed last report: polyp completely excised in single piece. Histology: LGD unable to assess completeness of excision due to fragmented specimen

11 4. What would you do next? 1. Relax, complete extubation 2. Change patient position again 3. Use buscopan 4. Use a snare to manipulate view of polyp 5. B & D

12 5: Change patient position again & Use a snare to view all polyp 5mm

13 5: What would you do next? 1. Photo-document residual stalk and complete extubation 2. Lift with EMR solution and hot snare close to base of polyp stalk 3. Biopsy and tattoo in case any residual tissue 4. Cold snare in case any residual polyp tissues

14 2: Lift with EMR solution and hot snare close to base of polyp stalk Polyp head appears malignant, firm to touch Trial of lifting solution, polyp lifted easily Polyp hot snared close to base Resected and retrieved by suction in single piece Polypectomy base examined carefully Histology: fragmented specimen: Adenocarcinoma, unable to assess completeness of excision

15

16 Lessons Use position change and adjunctive techniques to obtain optimal views Search for and identify polypectomy sites, especially if completeness of excision cannot be assessed Small and diminutive polyps should always be closely examined for features of malignancy (NBI/dye-spray) Always aim for complete resection Always aim to retrieve the (entire) specimen My mistake? If a resected polyp maybe malignant use a net rather than suction to prevent the specimen fragmenting

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