Endoscopic resection of a big duodenal polyp lesion with laparoscopic control

Large pedunculated gastrointestinal tract polyps are often difficult to remove by endoscopic polypectomy. In this video, whe show our approach to perform endoscopic resection under laparoscopic control in order to intervene should there be a massive bleeding or a perforation that could not be controlled endoscopically.

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Endoscopic resection of a big duodenal polyp lesion with laparoscopic control

Authors

D Coumaros, N Lakhrib, S Zirabe, J Leroy, J Marescaux

Abstract

Large pedunculated gastrointestinal tract polyps are often difficult to remove by endoscopic polypectomy. In this video, whe show our approach to perform endoscopic resection under laparoscopic control in order to intervene should there be a massive bleeding or a perforation that could not be controlled endoscopically.

Classification

tips and tricks

Keywords

Endoscopic resection, big duodenal polyp lesion, laparoscopic control

Media type

Surgical video

Duration

07'56''

Publication

2010-11

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E-publication

WeBSurg.com, Nov 2010;10(11).
URL: http://www.websurg.com/doi-vd01en2688.htm

Endoscopic resection of a big duodenal polyp lesion with laparoscopic control

1. Introduction 00'11''

This video shows the case of a 68-year-old man with a previous history of morbid obesity, renal insufficiency and alcoholic cirrhosis. For the last 6 months, he had melena with hemoglobin levels under 9 grams; his thrombocytes were at 99 000. When performing the endoscopy, stage 1 esophageal varices and a portal hypertensive gastropathy were observed, and a big eroded polyp at the second duodenum, suggestive of a submucosal lesion responsible for the melena. The patient was transferred for an endoscopic treatment due to his previous history and because of the difficulties involved in dealing with a large pedunculated polyp located on the external border of the second duodenum. The endosonography revealed that the lesion had an echogenicity suggestive of a lipoma.

2. Upper GI endoscopy 00'58''

The upper GI endoscopy was performed with an axially viewed gastroscope, then with a laterally viewed duodenoscope under laparoscopic control in order to intervene should there be a massive bleeding or a perforation that could not be controlled endoscopically.

3. Laparoscopic view 01'18''

Here we can see the laparoscopic approach of the pancreaticoduodenal region. Through trans-illumination, the laparoscopic view allows to see the endoscope in the duodenum and we uncover this large superficially ulcerated and pedunculated lesion on the external border of the second duodenum. The papilla was in a sub-diverticular position. There was a large diverticulum.

4. Removal of the polyp 01'59''

We try to get hold of this submucosal polypoid structure with an Endo-loop. At that moment, the pedunculated polyp introverts in the diverticulum situated just in front of the polyp’s foot. We therefore have to use a long foreign body grasper to exteriorize this polyp from the diverticulum and we will again attempt to perform a prophylactic hemostasis using an Endo-loop. Here we see the third attempt at a preventive hemostasis using an Endo-loop, which will this time allow to firmly hold the lesion’s pedicle; the first two attempts had failed but during this third attempt, we are faced with the fact that the Endo-loop can be tightened but cannot be reopened or completely taken off. This is due to the laterally viewed scope causing system stiffening. Therefore, we are obliged to divide the Endo-loop using endoscopic shears, before removing it and attempting the endoscopic resection again. We use the foreign body grasper again to exteriorize the polyp as it has a natural tendency to go into the third duodenum, and what is more, into a suprapapillary diverticulum. Using the graspers, we manage to reposition the polyp in the duodenum and we try to catch the polyp’s foot with a new Endo-loop. At that moment, and by avoiding as much as possible the use of the Albaran elevator, we manage to open, close, tighten and finally launch this Endo-loop. Then, by using a rigid polypectomy snare, we will try to encircle the polyp and find the right position to close the snare around the polyp’s foot. As we usually work blindly in these types of lesions, we manage to tighten the snare before having to untighten it to be slightly away from the Endo-loop as we want to avoid it being stuck between the loop and the polyp’s foot. However, this did occur. Finally, due to this insufficient repositioning, we had to divide part of the Endo-loop, causing a small bleed that is managed by the injection of thirty mL of normal saline solution containing 1:20 000 adrenaline. With a clear view of the lesion, the papilla, the diverticulum, we notice that the Endo-loop has been separated from the polyp’s foot and we decide to remove the Endo-loop. In the meantime, the polyp had been removed using a Roth Net. It measured 7 x 2.5 x 5cm and had a 1.5cm foot. Histologically, the lesion corresponded to a lipoma.