Endoscopic en bloc removal of appendiceal polyp facilitated by traction (2019)

Colonoscopy is widely used for the removal of colonic polyps to prevent the future development of colorectal cancer.1Seeff L.C. Richards T.B. Shapiro J.A. et al.How many endoscopies are performed for colorectal cancer screening? Results from CDC's survey of endoscopic capacity.Gastroenterology. 2004; 127: 1670-1677Abstract Full Text Full Text PDF PubMed Scopus (368) Google Scholar, 2Rex D.K. Schoenfeld P.S. Cohen J. et al.Quality indicators for colonoscopy.Gastrointest Endosc. 2014; 81: 31-53Abstract Full Text Full Text PDF PubMed Scopus (632) Google Scholar, 3Winawer S.J. The history of colorectal cancer screening: a personal perspective.Dig Dis Sci. 2015; 60: 596-608Crossref PubMed Scopus (48) Google Scholar However, incomplete resection of these precancerous colonic polyps often results in recurrent polyps4Moss A. Williams S.J. Hourigan L.F. et al.Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study.Gut. 2015; 64: 57-65Crossref PubMed Scopus (324) Google Scholar, 5Tate D.J. Desomer L. Klein A. et al.Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool.Gastrointest Endosc. 2017; 85 (e6): 647-665Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar and is also strongly associated (odds ratio, 4.76) with interval development of the colorectal cancer after previous colonoscopy.6Tollivoro TA, Jensen CD, Marks AR, et al. Index colonoscopy-related risk factors for postcolonoscopy colorectal cancers. Gastrointest Endosc. Epub 2018 Aug 23.Google Scholar Removal of polyps originating from the appendiceal lumen is especially difficult because of the inability to reach the deep margin of the lesion, resulting in a high rate (10%-15.6%) of residual adenoma.7Binmoeller K.F. Hamerski C.M. Shah J.N. et al.Underwater EMR of adenomas of the appendiceal orifice (with video).Gastrointest Endosc. 2016; 83: 638-642Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 8Song E.M. Yang H.J. Lee H.J. et al.Endoscopic resection of cecal polyps involving the appendiceal orifice: a KASID multicenter study.Dig Dis Sci. 2017; 62: 3138-3148Crossref PubMed Scopus (18) Google Scholar, 9Bronzwaer M.E.S. Bastiaansen B.A.J. Koens L. et al.Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a prospective observational case study.Endosc Int Open. 2018; 6: E1112-E1119Crossref PubMed Google Scholar Several recently published techniques were proposed to facilitate the endoscopic removal of these appendiceal polyps, including underwater EMR, the use of a double-channel gastroscope, and even full-thickness resection.7Binmoeller K.F. Hamerski C.M. Shah J.N. et al.Underwater EMR of adenomas of the appendiceal orifice (with video).Gastrointest Endosc. 2016; 83: 638-642Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 9Bronzwaer M.E.S. Bastiaansen B.A.J. Koens L. et al.Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a prospective observational case study.Endosc Int Open. 2018; 6: E1112-E1119Crossref PubMed Google Scholar, 10Tachikawa J. Chiba H. Kuwabara H. et al.Successful 2-channel cold snare polypectomy of a colorectal lesion involving the appendiceal orifice.VideoGIE. 2018; 3: 279-280Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar We now report on the use of a recently developed DiLumen (Fig. 1) double-balloon interventional platform (Lumendi LLC, Westport, Conn, USA) to facilitate the removal of a large (15-mm) polyp originating from the appendiceal lumen (Figure 2, Figure 3; Video 1, available online at www.VideoGIE.org). A PolyLoop (Olympus America, Center Valley, Pa, USA) was placed and tightened around the middle portion of the polyp (Fig. 4) to avoid catching the deep layers of the appendiceal wall. The PolyLoop was attached to the DiLumen’s dynamically adjustable foreballoon (Fig. 5) with the use of an endoscopic clip (QuickClip Pro; Olympus America). The aft-balloon was distended, stabilizing the DiLumen inside the ascending colon. Then the fore-balloon was retracted in the anal direction, pulling the polyp into the cecum and exposing the attachment of the polyp to the appendiceal mucosa (Fig. 6).Figure 2Schematic diagram demonstrating consecutive procedural steps: A, Polyp originating inside the appendix. B, A PolyLoop is tightened around the polyp and connected to the fore-balloon of the DiLumen. The fore-balloon is retracted in the anal direction, pulling the polyp into the cecum and exposing the attachment of the polyp to the appendiceal mucosa. C, Submucosal injection of normal saline solution under the polyp with endoscopic injection needle. D, The polyp is cut off from the site of its attachment. E, The polyp is removed. F, Mucosal defect after lesion removal is closed with 1 continuous endoscopic suture with the Overstitch endoscopic suturing device.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Adenomatous polyp growing from appendix into cecum.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4The Polyloop is tightened around the appendiceal polyp.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5The PolyLoop is attached to the fore-balloon of the DiLumen with endoscopic clip.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6The fore-balloon is retracted in the anal direction, pulling the polyp into the cecum and exposing the attachment of the polyp to the appendiceal mucosa.View Large Image Figure ViewerDownload Hi-res image Download (PPT) After the submucosal injection of normal saline solution underneath the polyp with an endoscopic injection needle (InjectorForce Max; Olympus America) (Fig. 7), the polyp was resected (Fig. 8) with use of the DualKnife (Olympus America) and removed en bloc (Fig. 9). The mucosal defect after removal of the lesion was closed with 1 continuous endoscopic suture (Fig. 10) by use of the Overstitch (Apollo Endosurgery, Austin, Tex, USA) endoscopic suturing device inserted through the conduit from the rectum to the ascending colon created by the DiLumen double-balloon platform. A postprocedural abdominal radiograph did not reveal any intraperitoneal air. After the procedure, the patient was discharged home in stable condition with no complaints. Pathologic examination of the specimen reported it as a tubular adenoma and confirmed R0 resection with negative margins.Figure 8The polyp is cut off with the DualKnife.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 9Specimen demonstrating 15-mm polyp after en bloc removal, with clearly visible normal mucosal resection margin.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 10Mucosal defect after lesion removal is closed with 1 continuous endoscopic suture using Overstitch endoscopic suturing device.View Large Image Figure ViewerDownload Hi-res image Download (PPT) In conclusion, endoscopic removal of a polyp originating inside the appendix can be difficult, resulting in incomplete resection with residual polypoid tissue left inside the appendix. The use of a traction device exposed the attachment of the polyp to the appendiceal mucosa and facilitated en bloc endoscopic removal of a difficult polyp with negative (R0) resection margins. Dr Kantsevoy is a consultant for Apollo Endosurgery, Aries, Endocages, LumenDi, Medtronic, Olympus, and Vizballoons; is a co-founder of Apollo Endosurgery and Endocages; is a shareholder in Apollo Endosurgery; holds equity in Endocages, LumenDi, and Vizballoons; is on the advisory board of LumenDi; and is in active litigation with LumenR. All other authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4NmIwYTc3NDZkYmFkNTk4MjEzOTI1MDJkZjRlODVjMiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc3NzgxOTUyfQ.pHjVUpXvX5svVrJv4V4Jrx6ytZpTJoS8ntbdVe1GI5aweoC3Rk9VIGYwjJVwajOUUPl9_vFU7G_He_h5TDQez9P57LMX9o0RS4fs_7X6XolD8Ddei-47oYxrygZh_KuDlKyxm4H0l6cFnSb6KASyWUdp-aGtv15jDLyiCvDaJed0zFr2EkHc1EyMsoesNQAY69e0IqqdLevjEoRHSou0BPm1KnNQ_mHkCBWPqDAh8oy9gnvzXu2SxnA8mCIChUmDETh8eAemEZVYd_eOBsu-mlO087eSUVIxKXH8bsDRH7x6GHiTESQzBg13DNqtykGW8akjyM7x4L4nUMsfZtqoRw Download .mp4 (46.14 MB) Help with .mp4 files Video 1Use of a double-balloon interventional platform to facilitate removal of a 15-mm polyp originating from the appendiceal lumen.