Band Ligation-Assisted Forceps Scissor Transection of a Unique Pedunculated Colorectal Lesion with Stalk Varices.

Abstract

An 81-year-old male patient presented for ileocolonoscopy for anemia workup. While smaller polypoid lesions in the remaining colon were resected without complications, an estimated 50-mm, complex pedunculated (Paris Ip) lesion with a unique multinodular, uneven surface was observed in the sigmoid (Fig. 1a). However, dedicated optical assessment of large areas of the lesion indicated adenoma-typical vessel and surface pattern, albeit full optical assessment of the large and floppy lesion was not feasible (EC760R-V/I; Fuji, Düsseldorf, Germany) (Fig. 1b). More intriguingly, the 25-mm-long and 10-mm-wide stalk demonstrated marked varices originating from adjacent flat sigmoid mucosa (Fig. 1c). Given concerns as to whether adequate placement of a snare and/or prophylactic loop would be feasible in consideration of the large head and markedly uneven surface, in this unique setting we opted for an individual approach, implementing stalk transection after endoscopic band ligation. To this end, we provided the insertion point at 35 cm with two rubber bands as per standard procedure (Fig. 1d, e). Alternatively, clip application at the stalk base might have been discussed for prophylactic hemostasis. However, this was decided against due to, among others, concerns for thermal injury. Cap-fitted gastroscope reinsertion exposed the edematous stalk with the ligations at 6 o’clock and the polyp head at 12 o’clock (Fig. 1f). Next, we completed an uncomplicated forceps scissor transection of the highly fibrotic stalk, using a scissor-type knife device, only at the first cut resulting in self-limited bleeding from ligated varices (Fig. 2a, b). Electrosurgical settings were as follows: transection (mucosa and submucosa): Endocut Q, effect 2, duration 3,