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We read with interest the article by Yen et al (Gut 2007;56:12) on a patient with obscure gastrointestinal bleeding in whom a juvenile polyp 1 cm in size, with a shallow ulcerated surface, was found in the jejunum on double balloon enteroscopy (DBE). Because the patient was receiving regular dialysis and because of the hypervascular nature of the polyp, it was resected surgically. In such cases, however, we believe that endoscopic polypectomy can safely be undertaken with the use of a detachable snare.
Major complications of endoscopic polypectomy are bleeding and perforation, which are most commonly associated with the removal of large polyps with thick stalks.1 For safer removal of large polyps, a detachable snare is designed for endoscopic ligation instead of a surgical suture.1 The snare is composed of an attached nylon loop and an operating part,1,2 2300 mm in working length, which makes the snare available for DBE. After the snare is placed at the base of the stalk, tightened around the stalk, and left in place to ensure haemostasis, endoscopic polypectomy is done near the head of the polyp.1,2 Endoscopic polypectomy of large pedunculated polyps with a detachable snare is reported to be safer than conventional polypectomy without the snare.1,2 In our case series with the use of the snare, neither immediate nor delayed bleeding occurred in any patient with a bleeding tendency.1
Juvenile polyps have been considered to be benign hamartomas or inflammatory growths with little or no malignant potential.2 They are common in children under the age of 10 years, and are generally located in the colon. Because juvenile polyps often manifest initially with bleeding and are usually pedunculated, endoscopic polypectomy is often indicated.2 We reported a one year old girl with a large juvenile polyp in the descending colon, in whom endoscopic polypectomy with a detachable snare was successfully carried out without complications.2 The resected pedunculated polyp with an eroded surface was 2 cm in size, and several arteries were present in the thick stalk.
Before the recent advance of DBE, our routine approach for small bowel diseases was transenterotomy panenteroscopy, assisted by laparoscopy with mini‐laparotomy, which can investigate the entire small bowel with a standard endoscope.3 DBE is a novel technique for visualising the entire small bowel, either by a peroral or a peranal approach, and provides high diagnostic yields and therapeutic capabilities such as polypectomy.4 During DBE, successful endoscopic polypectomy was reported in patients with Peutz–Jeghers syndrome.4 All 18 polyps, 1–6 cm in size, in the small bowel were resected without bleeding or perforation. We therefore believe that endoscopic polypectomy of jejunal polyps with a detachable snare during double balloon enteroscopy can be an effective and safe alternative.
Conflict of interest: None declared.