Expert live case teaching decision-making in complex polypectomy, featuring hybrid underwater ESD/EMR of a previously attempted duodenal lesion. Covers technique selection, intraoperative bleeding management with a systematic gravity-water-tamponade framework, and high-risk defect closure using mantis and retention clips. Includes candid discussion of when to transition from ESD knife to snare resection and the importance of patient positioning for optimal access.
Structured bleeding management framework — demonstrates the gravity-water-tamponade approach for managing intraoperative arterial bleeding during hybrid ESD in the duodenum, with real-time teaching narration.
"I'm a submucosal purist and I don't want to change from that unless I have to — if you immediately go for FTRD, you can end up with a very expensive and invasive solution when a submucosal approach was always possible."
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.
"On GIEQs, we want to show everything in its totality. We're not going to stop this movie just because David is feeling uncomfortable — it builds character, and the audience appreciates that."
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.
"When it comes to intraoperative bleeding, the first thing is to get gravity optimal. If you can't, use water. Then it's always a blood vessel — identify it, tamponade it, and treat it precisely."
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:
"The decision to move to a colonoscope too late was a mistake I take on myself. The view was so much better — this is something to put down for next time."
"Closure here is non-negotiable. These duodenal defects after previously attempted resection are extremely high-risk for delayed bleeding. The combination of mantis and retention clipping has given us foreclosure."
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.
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.
Arterial bleeding is encountered during ESD, providing an unscripted but highly educational demonstration of the operator's structured response:
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.
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."
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.
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:
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.
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.
| 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 |
Watch the full 77-minute procedure to see every step of this complex hybrid ESD from initial decision-making through to high-risk defect closure.
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