Scissor‐type knife stalk transection for a difficult‐to‐access pedunculated colorectal lesion

As reflected by recent European guidelines, hot snare polypectomy with mechanical hemostasis techniques has been embraced as the benchmark approach in the endoscopic resection of pedunculated colorectal lesions. ¹ As a sine qua non, this, however, implies unproblematic snare capture of the lesion, which sometimes is complicated by overly mobile polyps and/or in sharply angulated segments with difficulties in endoscopic control of resection. While scissor‐type knife resection of colorectal Paris Ip lesions has been pioneered recently utilizing a specific stag beetle endoscopic submucosal dissection knife (SBJr, Sumimoto Bakelite Co., Tokyo, Japan), Clutch Cutter‐based endoscopic resection (Clutch Cutter, Fuji, Düsseldorf, Germany) has not been reported in this specific setting. ² , ³ This is illustrated here on the occasion of a 78‐year‐old female patient undergoing ileocolonoscopy for anemia work‐up. In the sigmoid, an estimated 20‐mm pedunculated lesion with a thick stalk >5 mm came to our notion. (Figure 1(A,B)) Snare capture was considered difficult due to the subtotal lumen occlusion and insufficient visual control and was, therefore, not attempted in this unique case. Therefore, we first selected upfront scissor‐type knife resection for this difficult‐to‐access lesion. After generous injection of about 5 mL of an indigocarmine–saline mixture, mucosal incision was started using a gastric‐type grasping scissor forceps with a blade length of 3.5 mm due to the perpendicular approach (Figure 1(C)). The mucosal incision was extended (Figure 1(D)) over the circumference implementing the so‐called “paper cutting technique” whenever appropriate, already transecting most of the submucosal tissue of the stalk (Figure 1(E)). Finally, stalk transection was accomplished by cutting through minor residual submucosal bridges until the widely en bloc resected polyp could be retrieved (Figure 1(F)). The unremarkable resection bed was provided with two hemoclips. Final pathology indicated intraepithelial neoplasia with low‐grade dysplasia with a wide R0 status. Scissor‐type knife resection may be an attractive rescue and, for selected individuals, primary approach for management of difficult pedunculated colorectal lesions. However, it has to be noted that such scissor knife‐based approach is associated with much increased accessory costs and might thus, beyond representing an attractive rescue technique after failed snare capture, be prioritized for selected individual lesions in an upfront intent.

FIGURE 1.

(A,B) An estimated 20‐mm pedunculated (Paris Ip) lesion in the sigmoid with a thick stalk well of >5 mm and subtotal lumen occlusion. (C) Beginning of the mucosal incision using a 3.5‐mm Clutch Cutter device for scissor‐type knife resection (smaller blade length chosen to compensate for rather perpendicular approach). (D) Extension of the incision/cutting line (E) using the “paper cutting technique”. (F) Specimen retrieval after full stalk transection had been achieved by cutting through some residual tissue bridges within the submucosal plane

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.