Case Studies

Education

Using Hemoclips for Closure of a Complicated Endoscopic Mucosal Resection

Stephen Kim, MD

Clinical Instructor of Medicine

David Geffen School of Medicine at UCLA

Los Angeles, California, USA

Patient History

A 63-year-old man underwent routine colonoscopy for colorectal cancer screening. During the colonoscopy, a 2cm laterally spreading sessile polyp (Paris 0-IIa) was seen in the cecum adjacent to the appendiceal orifice (Figure 1). Biopsies of the polyp were consistent with a tubular adenoma. The patient was referred for endoscopic mucosal resection (EMR)..

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Procedure

The previously identified large 2cm polyp was seen in the cecum. One edge of the polyp appeared to be encroaching on the appendiceal orifice (Figure 2).The polyp was circumferentially lifted (Figure 3).

The Captivator™ II Single-Use Snares, 15 and 20 mm stiff round snares, were then used to remove the polyp in two pieces (Figure 4).

The final endoscopic mucosal resection defect was 2.5cm and showed no evidence of residual polyp and no bleeding or perforation was seen (Figure 5).

Due to the orientation of the polyp and difficult scope position, the hemoclip closure of the endoscopic mucosal resection site was an arduous task. Ultimately, the EMR site was completely closed using careful placement of three Resolution 360™ Clips (Figure 6).

Post Procedure

The patient tolerated the procedure without any complications. The final pathology of the polyp confirmed a tubular adenoma with no high grade dysplasia. The patient will return in 12 months for a surveillance colonoscopy to ensure that there is no recurrent or residual polyp at the resection site.

Discussion

This case demonstrates the ability to effectively close a complicated EMR site using the Resolution 360™ Clip. Although the size of the polyp was only 2cm, the polyp was located in the cecum where there is an increased risk of post-procedural bleeding. However, closing this EMR defect was more complicated than initial appearance due to the orientation of the polyp and the difficult scope position. The Resolution 360 Clip was pivotal in providing one-to-one control in order to position the clips in the exact alignment needed to close the defect. Three clips were placed in zipper fashion to completely close the resection site. The patient did not experience post-polypectomy bleeding.

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