Decision Making in Complex Polypectomy: Hybrid ESD, Bleeding Control, and Defect Closure — A GIEQs Live Case

Introduction

Previously attempted polypectomy represents one of the most demanding scenarios in therapeutic endoscopy. Residual or recurrent lesions are characterised by submucosal fibrosis, scarred margins, distorted anatomy, and an unpredictable injection response — all of which compound the technical challenges of standard resection. This expert live case from the GIEQs teaching library demonstrates a complete hybrid ESD/EMR workflow for a previously attempted duodenal lesion at the D1-D2 junction, with real-time decision-making commentary from initial assessment through to defect closure.

What makes this case particularly valuable for trainees is its honesty. Equipment limitations, difficult angles, intraoperative bleeding, patient positioning adjustments, and late decisions are all shown without editing — precisely the conditions that define real endoscopic practice.

Case Overview: When Surveillance Is Not Enough

The session opens with a case discussion that frames the critical clinical question: when should a large polyp that has previously been surveilled be resected? The assessment shows a lesion with significant fold convergence, raising the differential between malignancy and post-resection scarring. Systematic optical evaluation is essential — fold convergence alone does not define cancer, and this case illustrates how previous intervention dramatically complicates the endoscopic picture.

The key learning point: do not assign malignancy based on a single feature in a previously attempted lesion. A complete optical assessment, ideally by an experienced operator, is mandatory before committing to any management strategy.

Technique Selection: The Submucosal Purist Principle

Before injection, the operator articulates a guiding philosophy that shapes the entire case: "I am a submucosal purist. I do not want to change from that unless I have to." This means full-thickness resection techniques (FTRD) are not the default response to a difficult case — they are a last resort when submucosal access is genuinely lost. The default is to attempt underwater hybrid ESD first, accepting that the approach may need to evolve.

The chosen technique is a hybrid underwater ESD using saline as the distension medium, with an electrosurgical knife for circumferential incision and piecemeal snaring where anatomy allows. The setup includes:

• Generator settings: EndoCut Q effect 2 for cutting, Precise Sect 4.1 for underwater tissue dissection
• Injection medium: Colloid initially, then saline (after a reminder from the transcript's off-screen mentor about terminology)
• Snare selection: Captivator 2 from Boston Scientific as the primary resection snare; Snare Master Plus 15mm for piecemeal fragments
• Scope: Standard gastroscope transitioning to paediatric colonoscope (PCF) for improved access in the final stages

Live Case: Step-by-Step Teaching

Marking and Injection

Marking is performed with soft coagulation, with the operator acknowledging from the outset that the posterior margin is being marked wide to compensate for poor visualisation. The immediate jet sign on injection confirms expected submucosal fibrosis from previous intervention. The anterior margin demonstrates reasonable lift; the posterior does not — exactly as predicted. This is critical decision-making: knowing when a predicted finding confirms your approach rather than prompting retreat.

Hybrid Knife Incision

The circumferential incision begins underwater, exploiting the optical advantages of saline distension to define the submucosal plane. The operator uses a short knife tip to minimise perforation risk, particularly relevant in the duodenum where the wall is thin and folds create difficult working angles. Real-time commentary covers the challenge of CO2 accumulation diluting the underwater field, respiratory movement affecting stability, and the importance of managing water pressure to avoid obscuring tissue planes.

The transition from full knife ESD to piecemeal snaring is openly discussed mid-procedure: "I am not someone to just wish to continue with ESD for the sake of it. This is benign disease — if a snare becomes attractive at a certain point, fine." This pragmatic stance avoids the common trainee error of persisting with a difficult technique when a safer hybrid approach is clinically equivalent.

Intraoperative Bleeding Management

Arterial bleeding is encountered during ESD, providing an unscripted but highly educational demonstration of the operator's structured response:

1. Optimise gravity — reposition scope and patient to allow blood to pool away from the operative field
2. Fill with water — saline irrigation clears the field immediately where gravity alone cannot
3. Identify the source — every intraoperative bleed is a blood vessel; systematic cap-based tamponade identifies the precise point
4. Treat precisely — targeted soft coagulation rather than broad thermal application, which is highlighted as a major risk in the duodenum specifically

The operator explicitly references a serious historical complication from overuse of soft coagulation in the duodenum: "One of the worst complications I have ever had is overuse of soft coagulation in the duodenum — just let's be clear with each other. I was lucky." This level of transparency about personal experience and complications is rare in educational content and is part of what defines GIEQs teaching.

Piecemeal Completion and Margin Ablation

Once the dominant ESD portion is complete, piecemeal snaring is used to clear residual fragments. The operator compares this to "cutting a cauliflower" — short, precise snare bites using water distension to define fragment borders and prevent inadvertent muscle capture. Margin ablation with argon plasma coagulation or STSC is described as non-negotiable after hybrid evulsion-assisted procedures: "Part of the avulsion technique is putting STSC over the top — this is non-negotiable."

Access Optimisation: A Lesson in Late Adaptation

One of the most candid moments in the case is the operator's acknowledgement that the transition to a paediatric colonoscope (PCF) was made too late: "I should have used the PCF way earlier when I stopped doing ESD. This is a mistake — something to put down for next time. The view is so much better. The evulsion could have been more precise."

This is a valuable lesson for trainees: scope selection for complex duodenal lesions is not fixed. The PCF offers significantly better angulation at the D1-D2 junction, and switching midway through a procedure — though logistically demanding — can be justified when the standard gastroscope is limiting access to residual lesion or the defect.

Patient positioning is equally important. Drift from left lateral to supine position was identified as contributing to poor access during closure, and repositioning to fully lateral restored visualisation. In complex duodenal procedures, patient positioning should be actively managed throughout, not assumed to be stable.

Defect Closure: High-Risk Management

Closure is emphasised as mandatory for this case type. The operator explains: "These duodenal defects — especially in previously attempted cases — are extremely high-risk for delayed bleeding. A lot of the patients we ever admit for endoscopy are with duodenal bleeding after exactly this type of procedure."

The closure strategy employs a combination of:

• Mantis clip — for approximating the widest point of the defect initially
• Standard through-the-scope clips — for sequential closure along the defect length
• Olympus retention clips (12mm) — selected for their strength-to-cost ratio and short stem, which reduces the risk of impinging on adjacent structures

Partial closure followed by complete foreclosure is achieved, with discussion of the risk of bridging clips that might leave an open channel. The clip type discussion (EasyClip vs standard clips) is informative: EasyClip is rotatable and reopenable, which gives flexibility in difficult positions, while retention clips offer greater tensile strength for high-risk closure.

Post-Procedure Plan

Follow-up endoscopy is planned at one year. The resection site is staged as piecemeal with hybrid technique; histological clearance will be confirmed from the retrieved specimens. Delayed bleeding prophylaxis via closure is the primary mechanism; no pharmacological bridging is discussed.

Key Teaching Points Summary

• Be a submucosal purist: FTRD is a last resort, not a default for difficult duodenal lesions
• Predict and accept fibrosis: Jet sign in previously attempted cases is expected — don't stop, adapt
• Transition to piecemeal when appropriate: Hybrid ESD/EMR is not failure; it is pragmatic technique selection for benign disease
• Bleeding management is systematic: Gravity → water → tamponade → precise treatment. Avoid broad thermal application in the duodenum
• Scope selection matters: Switch to PCF earlier for complex D1-D2 lesions
• Closure is non-negotiable: Previously attempted duodenal cases carry high delayed bleeding risk; foreclosure with combination clips is the standard
• Patient positioning is dynamic: Actively manage throughout the procedure, especially during closure

Equipment Referenced

Equipment	Use	Key Feature
Olympus EZ 1500	Primary scope (preferred)	Superior underwater imaging in near-field, no near-focus switching needed
Paediatric colonoscope (PCF)	Rescue scope for D1-D2 access	Better angulation for distal duodenum
Captivator 2 (Boston Scientific)	Primary resection snare	Oval, stiff, hot-capable
Snare Master Plus 15mm	Piecemeal fragments	Hexagonal shape for smaller or irregular fragments
EndoCut Q effect 2	Cutting current	Allows cutting while flushing underwater
Precise Sect 4.1 (ERBE VIO3)	Underwater dissection	Preferred underwater cutting with coag component
Olympus retention clip 12mm	High-risk defect closure	Strength, short stem, cost-effective
EasyClip	Flexible closure	Rotatable and reopenable
Mantis clip	Wide defect approximation	Strong jaw, good for large gaps — use cautiously re: sharp teeth in ESD defects