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Case
A 60 year-old woman presented with an upper gastrointestinal bleed requiring two units of pack red blood cells. Upper endoscopy at the referring hospital demonstrated a 3 cm ulcerated subepithelial mass in the gastric cardia. After discharge, the patient was sent to our institution for further evaluation by a laparoscopic surgeon who requested re-evaluation with endoscopy and attempted endoscopic snare polypectomy.
Repeat upper endoscopy revealed a 3 cm polypoid subepithelial mass with a 5 mm superficial ulceration which was located in the gastric cardia approximately 4 cm from the gastroesophageal junction (Figures 1a and 1b). The lesion seemed to be on a stalk which was amenable to snare polypectomy, and therefore it was decided that EUS was not needed. A standard 27 mm diameter snare (Sensation Polypectomy Snare, Boston Scientific Corporation, Natick, MA) was able to be placed around the polyp stalk. The snare was able to move the lesion freely from the gastric wall. The snare polypectomy was initiated with coagulation current. Unfortunately the polyp stalk was broad, and the snare not only was unable to cut through the entire stalk, but the snare wires also became damaged which prevented removal of the snare wire off the stalk. Because the plan had been for the patient to go to surgery if the lesion could not be removed endoscopically, it was decided to leave the snare around the lesion such that it would be removed at elective laparoscopic surgery. To accomplish this, the snare cable wires were detached from the snare handle by using a wire cutter to cut the snare wires at the handle outside the body, the plastic sheath was pulled off the wires and out the patient’s mouth, and then biopsy forceps were used to push the 240 cm long snare cable wires completely into the stomach so that they were free floating in the stomach but still attached to the polypoid mass. Because the stuck snare was tightly squeezing the lesion stalk, it developed a bluish purple discoloration from venous congestion and some mild oozing of blood. In order to minimize the chances of severe bleeding from the partially resected polypoid lesion, two nylon loops (PolyLoop, Olympus America, Center Valley, PA) as well as two Resolution Endoscopic Clips (Microvasive, Boston Scientific Corporation, Natick MA) were placed around the base of the polyp in attempt to minimize bleeding risk (Figure 2).
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Figure 1a |
Figure 1b |
Figure 2 |
The patient was sent home immediately after the procedure. She returned 6 weeks later for a planned elective laparoscopic gastric resection. She denied any post procedure melena or abdominal pain. She had noted that the long snare wires had passed in her feces approximately 4 weeks after the snare had been placed. Therefore instead of proceeding with the planned laparoscopy, a repeat endoscopy was performed. This revealed that the previously noted subepithelial gastric cardia mass had fallen off, and the polypectomy site only showed tethered mucosa and scar tissue radiating from the polypectomy site, and one remaining endoscopic clip (Figure 3). Biopsies of the polypectomy site revealed normal mucosa.
Discussion
This case illustrates an inadvertent ligation resection of a large gastric subepithelial lesion. It appears that the tight ligation of the base of the lesion with a snare wire and nylon loops led to necrosis of the base and eventual sloughing off of the lesion, with residual scarring at the base. This is similar to what occurs during eradication of esophageal varices with band ligation or nylon loop ligation in which the ligated varices eventually fall off.1, 2 Band ligation is also commonly performed for internal hemorrhoid treatment.3 Endoscopic detachable loop ligation has also been reported as an alternative technique for removal of large hyperplastic gastric polyps and gastroduodenal angiomas. 4, 5
Rubber band ligation of small (<12 mm) gastrointestinal stromal tumors (GIST) has been reported.6 In this study of 29 patients, pathology proven gastric GISTs (either by deep well mucosal biopsy histology or EUS FNA cytology) which on EUS communicated with the muscularis propria were aspirated into an endoscopic cap and rubber band ligation performed. The lesions then developed ischemia and necrosis at the basis, and sloughed off, with ulcer formation and healing over the next 5 weeks. One patient developed post-ligation bleeding 3 days after band placement, which was managed with endoscopic clips.
The endoscopic ligation technique described in this case using a detachable loop or snare could be considered as an option for the removal of selected large subepithelial masses, especially in patients who might otherwise undergo a high risk surgical resection. A potential problem with this technique is that the pathology of the lesion will be unknown unless the lesion is first biopsied or undergoes EUS FNA, or unless it is retrieved from the stool, although in most cases the pathology can usually be suspected based on EUS findings. Additionally, there is a chance for delayed hemorrhage or perforation, although the magnitude of this risk is unknown. Although in this case no pre-polypectomy EUS was performed because the lesion appeared amenable to snare polypectomy, in general it would be advisable to perform an EUS to confirm either no involvement or very limited involvement of the muscularis propria if ligation resection is electively performed. References:
1. Laine L, el-Newihi HM, Migikovsky B, Sloane R, Garcia F. Endoscopic ligation compared with sclerotherapy for the treatment of bleeding esophageal varices. Ann Intern Med 1993; 119(1):1-7.
2. Sung JJ, Chung SC. The use of a detachable mini-loop for the treatment of esophageal varices. Gastrointest Endosc 1998; 47(2):178-181.
3. Shanmugam V, Thaha MA, Rabindranath KS, Campbell KL, Steele RJ, Loudon MA. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev 2005;(3):CD005034.
4. Lo CC, Hsu PI, Lo GH et al. Endoscopic banding ligation can effectively resect hyperplastic polyps of stomach. World J Gastroenterol 2003; 9(12):2805-2808.
5. Ljubicic N. Endoscopic detachable mini-loop ligation for treatment of gastroduodenal angiodysplasia: case study of 11 patients with long-term follow-up. Gastrointest Endosc 2004; 59(3):420-423.
6. Sun S, Ge N, Wang C, Wang M, Lu Q. Endoscopic band ligation of small gastric stromal tumors and follow-up by endoscopic ultrasonography. Surg Endosc 2007; 21(4):574-578.
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