“Snare-pulley” clip-with-line technique to prevent polyp migration after endoscopic resection of a polyp in the third portion of the duodenum

Endoscopic resection of a duodenal tumor carries a risk of loss of the resected specimen because peristalsis and gravity encourage its migration deep into the third part of the duodenum, which cannot generally be reached with an endoscope. The clip-with-line technique, using a double-channel endoscope, has been reported to be useful in avoiding the loss of the specimen ¹ ; however, the double-channel endoscope is a special instrument and not available at all institutions. We demonstrate a “snare-pulley” clip-with-line technique, which is a technique to prevent polyp migration that uses a conventional single-channel endoscope ( Video 1 ).

Video 1  The “snare-pulley” clip-with-line technique is used to prevent polyp migration after endoscopic resection of a polyp in the third portion of the duodenum.

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A 42-year-old man was referred for treatment for a 10-mm pedunculated polyp in the third portion of the duodenum. Endoscopic resection was performed using a single-channel endoscope (PCF-H290TI; Olympus Corporation, Tokyo, Japan). The lesion was being pulled toward the distal lumen by gravity, so it was likely that it would have migrated distally after resection. First, a nylon line was tied at the neck of an endoclip (Sure Clip; Micro-Tech Co., Ltd., Nanjing, China), and the endoclip was inserted through the channel. Second, the clip was attached to the stalk of the lesion ( Fig. 1 a ), after which the free end of the nylon line was threaded through the snare (SnareMaster Plus, 10 mm; Olympus Corporation), and the snare was inserted along the line ( Fig. 1 b, c ). Third, the polyp was successfully removed by snaring at the bottom of the stalk ( Fig. 1 c ). The specimen was retrieved after resection, without risk of its distal migration ( Fig. 2 ). Histological examination of the resected specimen showed a tubular adenoma with negative resection margins.

Fig. 1.

 A schema of the “snare-pulley” clip-with-line technique illustrating: a a clip with an attached nylon line placed on the stalk of the lesion; b, c the free end of the nylon line threaded through the snare, which is then inserted along the line; d successful removal of the polyp by snaring at the bottom of the stalk, without risk of polyp migration.

Fig. 2.

 Endoscopic view showing the specimen being retrieved after its resection without risk of migration.

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