Management of Large Pedunculated Lesions in the Fundus of the Stomach
For large pedunculated lesions in the gastric fundus with a stalk, endoscopic resection using hot snare polypectomy with prophylactic mechanical ligation of the stalk is strongly recommended to reduce bleeding risk. 1
Assessment and Preparation
- Evaluate the lesion characteristics including head size, stalk thickness, and any features suggestive of malignancy before attempting removal 1
- For pedunculated lesions with head ≥20 mm or stalk thickness ≥5 mm, prophylactic measures are essential to prevent bleeding complications 1, 2
- Perform detailed endoscopic examination to rule out signs of invasive cancer such as irregular surface architecture, mucosal depression, or radiating folds 1
Recommended Procedure
Prophylactic Measures for Bleeding Prevention
- Apply prophylactic mechanical ligation of the stalk using a detachable loop (Endoloop) or clips for lesions with head ≥20 mm or stalk thickness ≥5 mm 1
- The endoloop should be placed at the base of the stalk to effectively ligate the feeding vessel supplying the polyp 1, 3
- For large stalks where loop placement may be difficult, consider clip placement before or immediately after stalk transection 1
- Injection of 4-8 mL of 1:10,000 epinephrine into both the polyp head and stalk may be considered as an additional measure to reduce polyp size and improve en bloc resection 1
Resection Technique
- Use hot snare polypectomy for the resection of the pedunculated lesion 1
- Transect at the middle to lower stalk to provide adequate specimen for histologic assessment of potential stalk invasion 1
- When using an endoloop, place the electrocautery snare above the loop with sufficient room to prevent the endoloop from slipping off after transection 1
- Tighten the snare as much as possible to make the snared plane smaller than the plane that has been looped 1
Specimen Handling
- Retrieve the specimen en bloc to ensure ability to assess resection margins, rather than dividing the polyp head to facilitate through-the-scope retrieval 1
- En bloc retrieval is critical for accurate pathologic staging, especially when evaluating for potential invasive carcinoma 1
- Orient the specimen properly for pathological examination by flattening and fixing it at the periphery before immersion in formalin 1
Special Considerations
- If the lesion is very large (≥40 mm) or has a particularly thick stalk that makes conventional snare resection difficult, consider referral for endoscopic submucosal dissection (ESD) 4
- For lesions with suspected submucosal invasion or concerning features, endoscopic ultrasound (EUS) assessment prior to resection can help determine the depth of invasion and guide management 5, 6
- If the lesion appears to be a gastrointestinal stromal tumor (GIST), additional considerations for management may be necessary 1
Post-Procedure Management
- Perform detailed inspection of the post-resection site to identify features for immediate or delayed perforation risk 1
- Consider tattoo placement 3-5 cm distal to the resection site using sterile carbon particle suspension if future localization may be needed 1
- Document details of the procedure including tattoo injection (material, volume, position) in the endoscopy report 1
- For large pedunculated polyps with concerning histology, surveillance endoscopy should be scheduled according to pathology findings 1
Potential Complications
- Immediate or delayed bleeding is the most common complication, particularly for lesions with head ≥20 mm or stalk thickness ≥5 mm 1, 3
- Perforation is rare but can occur, especially with deep thermal injury 1
- If complications occur, most can be managed endoscopically with clips, thermal therapy, or additional mechanical closure techniques 7
By following this structured approach to large pedunculated lesions in the gastric fundus, endoscopic resection can be performed safely and effectively, avoiding unnecessary surgical intervention in most cases 7.