polypectomy, El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
Tubulo-Villous Adenoma. An 81 year-old female that was suffering anemia and was referred to us for colonoscopic evaluation, Four polyps were found, two at the rectum and two at the sigmoid, as well as multiple diverticula. Adenomatous polyps are, by definition, neoplastic. Although benign, they are the direct precursors of adenocarcinomas and follow a predictable cancerous temporal course unless interrupted by treatment. They can be either pedunculated or sessile. Adenomas are divided into 3 subtypes based on histologic criteria, (1) tubular, (2) tubulovillous, and (3) villous. According to World Health Organization (WHO) criteria, villous adenomas are composed of greater than 80% villous architecture. Tubular adenomas are encountered most frequently (80-86%). Tubulovillous adenomas are encountered less frequently (8-16%), and villous adenomas are encountered least frequently (5%).

Video Endoscopic Sequence 1 of 28.

Tubulo-Villous Adenoma.

 An 81 year-old female that was suffering anemia and was
 referred to us for colonoscopic evaluation, Four polyps
 were found, two at the rectum and two at the sigmoid, as
 well as multiple diverticula.

 Adenomatous polyps are, by definition, neoplastic.
 Although benign, they are the direct precursors of
 adenocarcinomas and follow a predictable cancerous
 temporal course unless interrupted by treatment. They can
 be either pedunculated or sessile. Adenomas are divided
 into 3 subtypes based on histologic criteria, (1) tubular, (2)
 tubulovillous, and (3) villous. According to World Health
 Organization (WHO) criteria, villous adenomas are
 composed of greater than 80% villous architecture. Tubular
 adenomas are encountered most frequently (80-86%).
 Tubulovillous adenomas are encountered less frequently
 (8-16%), and villous adenomas are encountered least
 frequently (5%).

 For more endoscopic details, download the video clip
 by clicking on the endoscopic image. Wait to be
 downloaded complete then Press Alt and Enter for full
 screen.
 All endoscopic images shown in this Atlas contain
 video clips. We recommend seeing the video clips in full
 screen mode.
The patient finally decided, five months later, to be treated by the polypectomy procedure. Between both pictures, the previous one and the later, the later macroscopic image displays many changes. It is very likely that abnormal macroscopic growth will occur in five months.

Video Endoscopic Sequence 2 of 28.

 The patient finally decided, five months later, to
 be treated by the polypectomy procedure. Between
 both pictures, the previous one and the later, the later
 macroscopic image displays many changes. It is very
 likely that abnormal macroscopic growth will occur in
 five months.

 
We have to decide between a convencional picemeal polypectomy or a mucosectomy EMR endoscopic mucosal resection.

Video Endoscopic Sequence 3 of 28.


 We have to decide between a convencional picemeal
 polypectomy or a mucosectomy EMR endoscopic mucosal
 resection.  


 
Therapeutic Intervention. The image and the video clip display a pedunculated polyp seen at the sigmoid, an endoloop that is being placed throughout the working channel of the scope. The endoloop was fixed and cut the pedicle of the polyp.

Video Endoscopic Sequence 4 of 28.

Therapeutic Intervention.

 The image and the video clip display a pedunculated polyp
 seen at the sigmoid, an endoloop that is being placed
 throughout the working channel of the scope.
 The endoloop was fixed and cut the pedicle of the polyp.
   
The image and the video clip display the endoop being applied to the pedicle which has been tightened around the stalk of the polyp. Ligation using suture or metallic clips is a basic surgical technique to prevent postoperative bleeding. Generally, there are nourish blood vessels in the stalk of the pedunculated polyp, and their diameter depend on the size of the polyp and the diameter of the stalk. It is essential to completely ligate the vessels or to prevent postoperative bleeding for pedunculated polyp with or without active bleeding.

Video Endoscopic Sequence 5 of 28.

 The image and the video clip display the endoop being
 applied to the pedicle which has been tightened around the
 stalk of the polyp.

 Ligation using suture or metallic clips is a basic surgical
 technique to prevent postoperative bleeding. Generally,
 there are nourish blood vessels in the stalk of the
 pedunculated polyp, and their diameter depend on the size
 of the polyp and the diameter of the stalk. It is essential to
 completely ligate the vessels or to prevent postoperative
 bleeding for pedunculated polyp with or without active
 bleeding.
 
More pressure is exerted by the handle of endoloop.

Video Endoscopic Sequence 6 of 28.

 More pressure is exerted by the handle of endoloop.

 
It is observed in the video the loosening of the polyp that was cut with the handle of the endoloop. The purpose was not the cutting but to perform the hemostasis.

Video Endoscopic Sequence 7 of 28.

 It is observed in the video the loosening of the polyp that
 was cut with the handle of the endoloop. The purpose was
 not the cutting but to perform the hemostasis.

The argon catheter is observed, stopping a small bleeding.

Video Endoscopic Sequence 8 of 28.

 The argon catheter is observed, stopping a small bleeding.
The image and the video display the final status of the first polypectomy.

Video Endoscopic Sequence 9 of 28.

 The image and the video display the final status of the
 first polypectomy. 

The next polyp is also in the sigmoid, but a little more difficult to snare, since it is located on the curvature, after the recto-sigmoid junction and there are several diverticulae nearby.

Video Endoscopic Sequence 10 of 28.

 The next polyp is also in the sigmoid, but a little more
 difficult to snare, since it is located on the curvature, after
 the recto-sigmoid junction and there are several
 diverticulae nearby. 
At first, we thought to place an endoloop on the pedicle,but afterwards we decided to use argon plasma coagulator, aiming at the reduction of its size, and then cautery will be applied to the wire loop to tight around the stalk of the polyp.

Video Endoscopic Sequence 11 of 28.

 At first, we thought to place an endoloop on the pedicle,
 but afterwards we decided to use argon plasma coagulator,
 aiming at the reduction of its size, and then
 cautery will be applied to the wire loop to tight around the
 stalk of the polyp.

We began the procedure by using the Argon Plasma Coagulator.

Video Endoscopic Sequence 12 of 28.

 We began the procedure by using the Argon Plasma
 Coagulator.

The image and the video clip display the effectiveness of the Argon Plasma Coagulator, reducing the size of the polyp and excisioning it afterwards.

Video Endoscopic Sequence 13 of 28.

 The image and the video clip display the effectiveness of
 the Argon Plasma Coagulator, reducing the size of the
 polyp and excisioning it afterwards.

 

More therapeutic action using APC.

Video Endoscopic Sequence 14 of 28.

 More therapeutic action using APC.

 

For more endoscopic details download the video clip.

Video Endoscopic Sequence 15 of 28.

 For more endoscopic details download the video clips.
 
Status post Argon Plasma Coagulator. At this moment we decided to put aside this procedure, with the purpose of taking it back in a second instance. The size reduction will be easier, doing the extraction with the diatermia snare. At this moment we decided to cut both polyps of the rectum, the big and the small one .

Video Endoscopic Sequence 16 of 28.

 Status post Argon Plasma Coagulator.
 At this moment we decided to put aside this procedure, with
 the purpose of taking it back in a second instance. The size
 reduction will be easier, doing the extraction with
 the diatermia snare. At this moment we decided to cut both
 polyps of the rectum, the big and the small one.
After one hour and twenty minutes, we continued the polypectomy of the remnant with snare excision.The goal to reduce it of size with APC has been fulfilled.

Video Endoscopic Sequence 17 of 28.

 After one hour and twenty minutes, we continued
 the polypectomy of the remnant with snare excision.
 The goal to reduce it of size with APC has been fulfilled.
After reducing the size of the polyp using argon plasma coagulator (APC). Cautery is applied to the wire loop which has been tightened around the stalk of the polyp.

Video Endoscopic Sequence 18 of 28.

 After reducing the size of the polyp using argon plasma
 coagulator (APC). Cautery is applied to the wire loop which
 has been tightened around the stalk of the polyp.

 
Piecemeal excision of the rectal adenoma. The image and the video clips display the procedure, that carried out with piecemeal excision. Large sessile polyps usually require piecemeal snare resection.

Video Endoscopic Sequence 19 of 28.

 Piecemeal excision of the rectal adenoma.
 
 The image and the video clips display the procedure, that
 carried out with piecemeal excision.
 Large sessile polyps usually require piecemeal snare
 resection.  

Placement of a snare wire over the head of the polyp. Cautery is applied to the wire loop which has been tightened around the stalk of the polyp.

Video Endoscopic Sequence 20 of 28.

 Placement of a snare wire over the head of the polyp.
 Cautery is applied to the wire loop which has been tightened
 around the stalk of the polyp.
 

 
 

 
The fragment of the polyps have fallen out. They are showed here, after the removal of the first fragment.

Video Endoscopic Sequence 21 of 28.

 The fragment of the polyps have fallen out.
 They are showed here, after the removal of the first
 fragment.

 
In this image and the video clip, is observed the biggest fragment of the polyps that has been excisioned.

Video Endoscopic Sequence 22 of 28.

 In this image and the video clip, is observed the biggest
 fragment of the polyps that has been excisioned.
 
More tissue is being excisioned with the diatermia snare.

Video Endoscopic Sequence 23 of 28.

 More tissue is being excisioned with the diatermia snare.
The fragment that has been cut is observed. Excised polyp, waiting to be retrieved.

Video Endoscopic Sequence 24 of 28.

 The fragment that has been cut is observed.
 Excised polyp, waiting to be retrieved. 

A tiny rectal polyp has been excicioned.

Video Endoscopic Sequence 25 of 28.

 A tiny rectal polyp has been excicioned. 

The polyp is excised piecemeal using a snare. The image and the video clip display a fragment that has been cutting from the adenoma.

Video Endoscopic Sequence 26 of 28.

 The polyp is excised piecemeal using a snare.
 The image and the video clip display a fragment that has
 been cutting from the adenoma. 
Status post endoscopic polypectomy after the adenoma was performed with piecemeal snare resection.

Video Endoscopic Sequence 27 of 28.

 Status post endoscopic polypectomy after the adenoma
 was performed with piecemeal snare resection.  

Another image and video clip of the status post endoscopic polypectomy. The entire colon must be examined during the polypectomy so that any synchronous lesions can be detected and removed. Approximately 50% of patients will have a second adenomatous polyp at the time of initial colonoscopy, while metachronous polyps are found in 20-50% of patients within five years of the initial polypectomy. If follow-up colonoscopy verifies that no residual polyps exist, colonoscopy should be repeated within three years and thereafter every five years.

Video Endoscopic Sequence 28 of 28.

 Another image and video clip of the status post endoscopic
 polypectomy.
 The entire colon must be examined during the polypectomy
 so that any synchronous lesions can be detected and
 removed. Approximately 50% of patients will have a
 second adenomatous polyp at the time of initial
 colonoscopy, while metachronous polyps are found in
 20-50% of patients within five years of the initial
 polypectomy. If follow-up colonoscopy verifies that no
 residual polyps exist, colonoscopy should be repeated
 within three years and thereafter every five years.