Endoscopic removal of a giant double-headed fibrovascular esophageal polyp

A surgical approach is generally recommended for the excision of giant esophageal fibrovascular polyps. This strategy ensures adequate hemostasis and a clear resection margin at the base.

A 50-year-old man presented with a 6-month history of a globus sensation, mild intermittent dysphagia, occasional heartburn, and epigastric pain. Previous barium swallow, upper-GI endoscopy, and EUS demonstrated a giant doubleheaded polyp arising at the level of the cricopharyngeus, with bifurcation of the polyp 45 mm from the base (Fig. 1A). This lesion originated from the submucosal layer, with an inhomogeneous echo texture and a highly vascular stalk. The total length of the fibrovascular polyp was 13.5 cm. Our patient declined surgical intervention; hence, we opted for safe endoscopic resection in a piecemeal fashion after the application of multiple endoloops (Figs. 1B-E).

Figure 1.

A, Upper-GI endoscopic view of giant fibrovascular polyp arising from the upper esophagus just near the level of the cricopharyngeus. Note huge submucosal appearance that occupies approximately the whole esophagus and has a smooth overlying mucosa of the body. B-E, General scheme of the removal of the giant esophageal fibrovascular polyp. B, C, Two endoloops, one after another, applied at the level of the ramification of the polyp body. The first portion of the polyp is cut. D, E, Another 2 endoloops are placed at the very base of the stalk and securely tightened. The remaining portion of the polyp is resected. F, First nylon endoloop is placed at the level of the ramification of the polyp body and tightened securely. The scope is then exchanged for a double-channel therapeutic gastroscope. Grasping forceps are used to manipulate the polyp in view of the difficulty of placing the edematous polyp through the second loop. G, Resection of the first 75-mm portion of the giant fibrovascular polyp above 2 endoloops in endocut mode with the 25-mm electrosurgical snare. H, The second loop is applied right over the first loop and tightened strongly, mainly to prevent possible profuse bleeding and perforation. The second portion of the polyp is removed above the loops. Resected giant fibrovascular polyp. I, Overall appearance of polyp. Total length, 13,5 cm; distal head, 32 mm in diameter with 2 ulcerations on the apex; proximal head, 25 mm in diameter. J, Cross-section at the level of the base of the polyp, 18 mm in diameter (note the large vessels). K, Ligated 10-mm stalk stump of the polyp left in place. L, M, Histologic appearance showing mixture of fibrous and adipose tissues accompanied by abundant network of large vessels, covered by normal squamous epithelium. (L, H&E, orig. mag. ×5; M, H&E, orig. mag. ×20.) N, Surveillance gastroscopic view at 18 months revealing no changes of esophageal wall and mucosa, with no evidence of recurrence.

Removal of the polyp (Video 1, available online at www.VideoGIE.org) was performed with the patient under general anesthesia with CO₂ insufflation. We started the procedure with a diagnostic endoscope, and the first nylon 30-mm endoloop was placed at the level of the bifurcation of the polyp body (Fig. 1F). We then exchanged the endoscope for a double-channel therapeutic gastroscope. The second loop was placed directly at the level of the first and was tightened to prevent bleeding during resection. We placed a 25-mm electrosurgical snare above the 2 endoloops (Fig. 1G) and resected the first 75-mm portion of the polyp using endocut mode (Endocut Q, effect 2, duration 2, interval 6). Next, we placed 2 more endoloops at the base of the pedicle, and the remaining portion of the polyp was cut with a snare (Figs. 1H-J), leaving the ligated 10-mm stalk stump in place (Fig. 1K). There were no postoperative adverse events. The patient was discharged from the hospital 3 days later. Histologic examination of the polyp demonstrated a mixture of fibrous and adipose tissues accompanied by the large vessels (Figs. 1L and M). Surveillance gastroscopy at 18 months revealed no evidence of recurrence of the polyp (Fig. 1N).

We concluded that removal of a giant esophageal polyp using modern endoscopic equipment can be safely performed without surgical assistance.

Disclosure

All authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Endoscopic removal of a giant double-headed fibrovascular esophageal polyp.