A 73‐YEAR‐OLD MAN was admitted to our hospital with epigastric pain, anemia (hemoglobin 10.9 g/dL) and weight loss (8 kg in 6 months). Esophagogastroduodenoscopy (EGD) showed a gastric fundus polyp approximately 15 cm length (Figs 1,2). Random polyp biopsies showed a tubular-type adenoma with low-grade dysplasia (LGIEN). Gastric mucosal biopsies were negative for Helicobacter pylori and atrophy. Surgical excision would have implied the potential risk of cardiac insufficiency or necessity for gastrectomy. According to the votum of our interdisciplinary board and at the patient’s request, we decided against surgery and laparoscopic endoscopic cooperative surgery (LECS) and proceeded to endoscopic polypectomy. Endoscopic submucosal dissection (ESD) to remove the adenoma en bloc in a single session would be the desired approach in terms of histological assessment, reduction of (delayed) endoscopy-related complications and patient comfort. Lacking full view over the adenoma base and due to poor accessibility, we did not primarily apply ESD but chose a multi-step approach (Video S1 and S2). First, we removed the adenoma body by piecemeal hot snare polypectomy. Next, we removed the adenoma base by a combination of ESD and endoscopic mucosal resection (EMR). Eventual histology showed a pyloric-type adenoma with mainly LGIEN and no signs of invasive growth. Highgrade dysplasia (HGIEN) comprised less than 10% of polyp volume. We did not encounter any serious endoscopyrelated complications. Follow-up EGD after 5 and 11 months showed a well-healed resection site without adenoma remnants. Conclusion: In rare cases, gastric

中文翻译：

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多步内镜黏膜切除和黏膜下剥离混合技术在内镜下切除高度异型增生的巨大胃底腺瘤

一名 73 岁男性因上腹痛、贫血（血红蛋白 10.9 g/dL）和体重减轻（6 个月 8 kg）入院。食管胃十二指肠镜检查 (EGD) 显示一个约 15 cm 长的胃底息肉（图 1,2）。随机息肉活检显示具有低度不典型增生（LGIEN）的管状腺瘤。胃黏膜活检显示幽门螺杆菌和萎缩呈阴性。手术切除可能暗示心功能不全的潜在风险或胃切除术的必要性。根据我们跨学科委员会的投票和患者的要求，我们决定不进行手术和腹腔镜内窥镜合作手术（LECS），并进行了内窥镜息肉切除术。就组织学评估、减少（延迟的）内窥镜相关并发症和患者舒适度而言，内窥镜黏膜下剥离术 (ESD) 在单个疗程中切除腺瘤将是理想的方法。由于缺乏对腺瘤基底的全面了解，并且由于可及性差，我们没有主要应用 ESD，而是选择了多步骤方法（视频 S1 和 S2）。首先，我们通过分段热圈套器息肉切除术去除了腺瘤体。接下来，我们通过 ESD 和内窥镜黏膜切除术 (EMR) 的组合去除了腺瘤基底。最终的组织学显示幽门型腺瘤主要是 LGIEN，没有侵袭性生长的迹象。高度不典型增生（HGIEN）占息肉体积的不到 10%。我们没有遇到任何严重的内窥镜相关并发症。5 个月和 11 个月后的随访 EGD 显示切除部位愈合良好，无腺瘤残留。结论：在极少数情况下，胃