S4166 Successful Hybrid Endoscopic Submucosal Dissection-Endoscopic Mucosal Resection Technique for Resection of a Large Polyp at the Ileocecal Valve

Introduction: Endoscopic mucosal resection (EMR) of polyps at the ileocecal valve (ICV) can be challenging due to flatness of lesions and extension into the terminal ileum with a high risk of recurrence. While endoscopic submucosal dissection (ESD) allows for en-bloc resection of polyps with lower risk of recurrence, this technique can be difficult for polyps at the ICV due to anatomic complexity, fatty submucosa, and thin-walled cecum/ascending colon with higher risk of adverse events. However, utilization of EMR after initial ESD (hybrid ESD-EMR) can allow for effective resection for polyps at the ICV with benefits of both techniques. Herein, we describe a case of successful hybrid ESD-EMR for a large 40 mm polyp at the ICV. Case Description/Methods: A 64-year-old woman with history of hyperlipidemia was referred for management of a large polyp at the ICV. Colonoscopy with white light exam demonstrated a 40 mm polyp at the ICV with two-thirds circumferential extension into the terminal ileum. The polyp was classified as homogenous granular lateral spreading and NICE II pit pattern on narrow band imaging. A lifting solution of 6% hetastarch and indigo carmine was injected along the ileal aspect to ‘evert’ the polyp. A circumferential incision was subsequently made around the lesion and into the submucosa with ESD knife often under saline immersion. This technique creates a ‘trench’ for the snare to anchor into the lesion and thereby ensure negative margins at the ileal aspect. The polyp was resected in a piecemeal fashion using hot snare EMR. The lesion was successfully retrieved and the terminal ileum was patent at the end of the procedure. There were no adverse events associated with the procedure. Final histopathology demonstrated tubulovillous adenoma without high grade dysplasia. Surveillance colonoscopy at 6 months demonstrated no recurrence of disease. Discussion: Our case highlights successful hybrid ESD-EMR technique for resection of a large polyp at the ICV. Future studies should compare this technique to alternative endoscopic methods for management of large polyps at the ICV. Watch the video: https://tinyurl.com/25ACGS4166