Double-scope resection of a large duodenal polyp

Abstract

An 83-year-old man underwent right colectomy with ileostomy because of Ogilvie syndrome with perforation of the ascending colon. After 10 days, the patient, who had multiple co-morbidities, had a myocardial infarction without ST-segment elevation. For this reason, percutaneous coronary intervention with the application of bare metal stents was required, and he subsequently received the standard dosage of antiplatelet therapy with acetylsalicylic acid and clopidogrel. Because of recurrent episodes of upper gastrointestinal bleeding with hematemesis and a decreasing hemoglobin level, an esophagogastroduodenoscopy was performed, which identified a large, bleeding, pedunculated polyp at the duodenal bulb (• " Fig. 1,• " Fig. 2). Because the stalk of the polyp was more than 10 cm long, it was impossible to pull the endoscopic snare (FlexSnare; Medwork, Höchstadt/Aisch, Germany) around the stalk. Therefore, an attempt was made to resect the polyp by bending the stalk into a U-shape close to its base in the polypectomy snare (• " Fig. 3). Resection with electrocoagulation was intended, but meanwhile bleeding occurred. After the injection of epinephrine 1 : 10 000 and the application of hemoclips (Long Clip HX-610-090L; Olympus, Tokyo, Japan), a clear view was restored. The stalk of the polyp had a diameter of approximately 1 cm. The endoscopic snare failed to cut through the whole polyp stalk, which was folded at its base, and caused only tangential injury. An effort was made to dissect the remaining polyp stalk by using the tip of the polypectomy