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Small Polyps

According to guidelines of the German Society of Digestive and Metabolic Diseases (DGVS) (3) polyps < 5 mm are removed using biopsy forceps; attempted snare polypectomy usually "burns" the polyp, rendering histological evaluation impossible (Fig. 18.2). The small polyp should be repeatedly grasped with the forceps until it appears macroscopically to have been completely removed. This method entails the risk, however, that macroscopically undetectable polyp pieces may remain and could cause residual polyps. For this reason, some authors prefer the hot-biopsy forceps method (8), which enables the retrieval of histologically valuable material while coagulating the base of the resection site. However, this method entails risk of rebleeding and perforation.

Stalked Polyps

It should be possible to remove stalked polyps of any size in a single session using a snare.

Ensnaring the polyp head and positioning the snare. An appropriate snare is selected, looped around the polyp head, and then positioned around the stalk. The level of transection or coagulation should be closer to the polyp head than to the bowel wall

(Fig. 18.3). Transection too close to the bowel wall may cause perforation; also, if rebleeding occurs from the remaining stalk, endoscopic hemostasis using injection or application of hemo-clips is much easier with more remaining stalk (Fig. 18.4). The snare should not be closed until it is exactly at the transection line. Closing the snare too firmly before diathermy can "guillotine" the polyp stalk and cause bleeding. Polypectomy must always be performed under visualization: insufficient visualization can result in perforation of the bowel wall. If the polyp head is so large that even a giant snare cannot be looped around it, it should be removed in several pieces or portions ("piecemeal" polypectomy). This can reduce the size of the polyp head so that the snare can then be placed around the stalk and the polyp can be safely and completely removed.

Coagulation of the polyp stalk. Polypectomy is performed using a mixture of coagulation and cutting current (monopolar blended current, 120 W), which is a standard setting in most recent electrocautery units. The snare must be closely encircled around the polyp stalk. When the coagulation effect on the stalk becomes visible, the snare can be closed more tightly. Cutting current may be increased if there is continued resistance against the closed snare, despite sufficient coagulation. Resection of stalked polyps can also be performed using pure coagulation current (60 W) to minimize risk of rebleeding from the polyp stalk.

Bleeding prevention measures. A very prominent stalk or obvious pulsating is usually a sign that the polyp head is being supplied by a thick vein, perhaps even an artery. In such cases, the examiner must consider how to minimize the risk of rebleeding by endoscopic treatment of the stalk prior to polypectomy. There are three possibilities that may be used in combination with each other (8):

1. An Endoloop (detachable nylon loop) may be placed around the polyp stalk. Like a polypectomy snare, a detachable snare is wide enough to be placed around the polyp head and positioned around the stalk. The detachable snare should be positioned closer to the bowel wall, as the polypectomy snare will later be placed above it and sufficient space must be left between the snare and the polyp head for safe and complete polypectomy. The Endoloop is then closed, ligating the stalk and vessel. Positioning the polypectomy snare can be extremely difficult and often optimal positioning is impossible due to the presence of the Endoloop. Following polypectomy, the Endoloop later falls off after necrotization of the stalk. Rebleeding at that time is rare. E 18.2 shows snare removal of a polyp with a thick, pulsating stalk using an Endoloop for assistance.

2. The polyp stalk can be injected with 0.9% NaCl and/or an epinephrine dilution of 1:100000 (Fig. 18.5). Injection technique is described in more detail in the section "Mucosectomy" p. 173. The dilution of epinephrine (1:100000 or 1: 10000) varies in the literature (8). The more concentrated form of epinephrine (1: 10000) tends to be indicated for achieving hemostasis with rebleeding following poly-pectomy.

Fig. 18.5 a, b Large stalked polyp. Injection of the polyp stalk with 0.9% NaCl and/or an epinephrine dilution of 1:100 000.

Fig. 18.5 a, b Large stalked polyp. Injection of the polyp stalk with 0.9% NaCl and/or an epinephrine dilution of 1:100 000.

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