title: Can endoscopic submucosal dissection technique be an alternative treatment option for a difficult giant (≥ 30 mm) pedunculated colorectal polyp?
abstract: BACKGROUND
  Snare polypectomy of a giant pedunculated colorectal polyp is sometimes technically demanding, and, therefore, piecemeal resection is inevitable, despite the relative risk of invasive cancer and postpolypectomy bleeding.
  
  
  OBJECTIVE
  The aim of this study was to evaluate the efficacy and safety of endoscopic submucosal dissection in comparison with conventional snare polypectomy for giant pedunculated polyps
  
  
  METHODS
  We retrospectively reviewed the clinical outcomes and complications of endoscopic polypectomy for giant pedunculated polyps from October 2006 to November 2011.
  
  
  METHODS
  All the patients who underwent endoscopic submucosal dissection (n = 23) or snare polypectomy (n = 20) for pedunculated polyps ≥ 3 cm were enrolled consecutively. In the case of a giant pedunculated polyp with 1) poor visualization of the stalk, 2) technical difficulties in snare positioning for en bloc resection, or 3) need for trimming of the head, we did not attempt piecemeal snare polypectomy, and we performed endoscopic submucosal dissection instead. (These were arbitrarily defined as "difficult" giant pedunculated polyps.)
  
  
  METHODS
  Data on the patient's demography, endoscopic and histopathologic findings, clinical outcomes, and complications were analyzed.
  
  
  RESULTS
  Among the 43 giant pedunculated polyps, 23 polyps were defined as "difficult" polyps and were removed with endoscopic submucosal dissection. Subpedunculated (stalk <1 cm) type was more common in the "difficult" polyp group (p = 0.01). The overall incidence of cancer was 18.6% (8/43). En bloc resection rates were 100% (23/23) in the endoscopic submucosal dissection group and 90% (18/20) in the snare polypectomy group. The procedure times of snare polypectomy and endoscopic submucosal dissection group did not differ significantly (41.7 ± 13.7 minutes vs 44.9 ± 35.6 minutes, p = 0.70). Postpolypectomy bleeding was noted in 1 case (4.3%) in the endoscopic submucosal dissection group and in 3 cases (15%) in the snare polypectomy group.
  
  
  CONCLUSIONS
  Endoscopic submucosal dissection, as well as the snare polypectomy for giant pedunculated polyps, appeared to be effective without major complications and can be an alternative option to achieve en bloc resection, particularly for difficult cases, such as giant subpedunculated polyps.
authors.affiliation: Department of Gastroenterology, Daehang Hospital, Seoul, Korea.
authors.forename: Yong Sung
authors.initials: YS
authors.lastname: Choi
authors.forename: Jae Bum
authors.initials: JB
authors.lastname: Lee
authors.forename: Eun-Jung
authors.initials: EJ
authors.lastname: Lee
authors.forename: Suk Hee
authors.initials: SH
authors.lastname: Lee
authors.forename: Jung Pil
authors.initials: JP
authors.lastname: Suh
authors.forename: Doo Han
authors.initials: DH
authors.lastname: Lee
authors.forename: Do Sun
authors.initials: DS
authors.lastname: Kim
authors.forename: Eui Gon
authors.initials: EG
authors.lastname: Youk
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003110:Colonic Neoplasms / Q000601:surgery*; D003111:Colonic Polyps / Q000473:pathology / Q000601:surgery*; D003113:Colonoscopy / Q000379:methods*; D004210:Dissection / Q000379:methods*; D005260:Female; D006801:Humans; D007417:Intestinal Polyps / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019106:Postoperative Hemorrhage / Q000453:epidemiology; D012002:Rectal Diseases / Q000601:surgery*; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult