In this episode of the Gastroenterology and Endoscopy podcast, we discuss a challenging case involving a pedunculated duodenal adenoma. These types of polyps present unique challenges for endoscopists, requiring meticulous planning for a successful procedure. The goal is to achieve a complete R0 resection, removing the entire lesion without leaving any microscopic remnants. We explore strategies to prevent migration of the polyp into the bowel, such as positioning the patient in a decubitus supine position or using an antimotility agent. The endoscopist and assistant must be on high alert to catch the polyp with the snare, and having a Roth's net on standby is recommended.Chapters:[00:02:16] Preventing complications.[00:04:10] Preparation is key.Resources:Endoscopic Resection of Complex Duodenal PolypsDuodenal Polyp Resources on EndoCollabQuotes:00:02:52 - "By allowing the neoplasm to float, we reduce the chances of transmitting electrosurgical current to the base of the lesion, minimizing the risk of perforation."00:03:06 - "And when it comes to closing the wound post-resection, clips are a must."Topics Discussed:Introduction to Pedunculated Duodenal Adenoma: Brief description of the polyp’s location and importance of meticulous planning for resection.Achieving Complete Resection (R0): Importance of removing the entire lesion and considerations to make during resection.Preventing Polyp Migration: Strategies to prevent the polyp from moving into the distal bowel.Complication Prevention: Discussion on measures to prevent complications during and after endoscopic resection.Tools and Techniques: Exploration of various tools (snare, Roth’s net, distal transparent cap) and techniques (submucosal injection, underwater resection, use of endoloops and clips).Managing Immediate and Delayed Bleeding: Importance of using endoscopic clips and hemostatic hydrogels, especially in patients on anticoagulation.Proximity to the Papilla of Vater: Ensuring correct identification of the lesion’s location and planning the resection accordingly.Post-procedure Care: Importance of starting proton pump inhibitors post-procedure.Final Thoughts and Goodbye: Summing up the key takeaways from the episode and bidding farewell to the listeners.Keywords:Gastroenterology, Endoscopy, pedunculated duodenal adenoma, endoscopic procedures, complications,closing the wound, post-resection, clips, duodenal endoscopic resections, bleeding complications, hemostatic hydrogels, Puristat, anticoagulation, proton pump inhibitors, healing process, polyp's proximity, papilla of vater, ampullary lesion, resection, side-viewing endoscope, complete R0 resection, pedunculated duodenal adenomas, preparation, plan, outcome, patient, insightful, helpful, practice