HUGE LST IN ASCENDING COLON WITH SUSPICIOUS NODULE [Video]

A 72 year old lady was found to be FIT+ve under the UK Bowel Cancer Screening Programme. The index colonoscopy was performed 6 weeks ago by a colleague and was reported as showing a “6cm LST-M across at least 3 folds in the ascending colon, NICE 2.” Several photographs were taken under white light and NBI. Biopsies were not taken to avoid fibrosis. The case was discussed in the complex polyp MDT and subsequently referred for elective polypectomy (see video).

When I performed the second colonoscopy, the LST looked larger than 6cm and although most it displayed Kudo pit pattern IV, there was a distinct central nodule which was firmer and displayed Kudo pit pattern V. This nodule was not mentioned in the index colonoscopy report. Bearing in mind that no biopsies were taken at the previous procedure, the nodule looked suspicious. I was in two minds about aborting the procedure. However as the nodule was quite small (about 1cm in diameter), I decided to continue (see video)…

The video is quite long (23 mins) but please view it to the end.

The video highlights:
– Using a paediatric colonoscope with a transparent cap.
– Achieving good lift with submucosal injection, topping up during the procedure as necessary.
– Positioning patient correctly to benefit from gravity.
– Meticulously removing all polyp tissue around the nodule, which is left to the end.
– Snaring the nodule in one go using a correctly sized snare.
– Recognising deep mural injury and its grade.
– Closing areas of deep mural injury with clips.
– Using Coagrasper to coagulate large vessels on the base of the defect.
– Using snaretip softcoag to treat edges of the defect.
– Using Purastat gel to cover raw surface of defect.
– Collecting all pieces of the polyp using multiple passes of a Roth net.