No Endoscope Free-Hand Polypectomy of a Large Rectal Polyp

CASE REPORT An 82-year-old woman was referred for evaluation of bleeding, fungating anorectal mass. Examination showed a firm, large 4-cm polypoid mass on a stalk that was protruding out of the anus. The size and consistency of the polyp head made it impossible to reduce it back into the rectum. Colonoscopy revealed that this was a large, Paris class 1p polyp with a long pedicle originating from the midrectal mucosa. With a gentle outward tug, the polyp could be pulled away from the anus with the stalk clearly visible. Careful examination showed no evidence suggestive of deeper invasion or inclusion of the muscular layer in the pedicle. After carefully pulling the polyp away from the anus, the base of the stalk was secured with a PolyLoop to mitigate bleeding risk (Figure 1). A complete en bloc resection was then performed using hot-snare polypectomy (Figures 2 and 3). Resection margins were free of adenomatous tissue and showed no evidence of deeper injury (Figure 4). Pathology showed tubulovillous adenoma with multifocal superficial high-grade glandular dysplasia with negative resection margins. There was no evidence of local recurrence on a follow-up colonoscopy after 6 months. This technique could be an option for large pedunculated polyps close to the dentate line, where conventional endoscopic resection can be challenging. Tension on the polyp stalk and risk of entrapment of deeper colonic layers could increase the potential for procedure-related adverse events such as bleeding, perforation, or postpolypectomy syndrome. Polyp characteristics and endoscopist skills should determine the selection of appropriate cases, comparing the risks and benefits with a conventional endoscopic or surgical approach. Caution should also be exercised when using electrocautery without an endoscope to prevent injury to the endoscopist or assisting staff. To the best of our knowledge, this is the first reported case of a freehand hot-snare polypectomy using standard endoscopy tools performed outside the lumen without an endoscope.Figure 1.: Base of the polyp stalk secured using PolyLoop.Figure 2.: Hot-snare polypectomy performed distal to the PolyLoop.Figure 3.: Resected specimen measuring about 4 cm.Figure 4.: Resection base.DISCLOSURES Author contributions: H. Gopakumar: conceptualization, data collection, writing, and approving the final manuscript; AC. Nekkanti: manuscript writing and approving the final manuscript; Eugene N. Annor: manuscript writing and approving the final manuscript; I. Balouch: approving the final manuscript; and I. Balouch is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.