Endoscopy: Polypectomy

Polypectomy

Incomplete Resection Considerations

  • Risk:
    • Adenomas ≤ 5 mm: 8-38%
    • Adenomas 5-20 mm: 10%
  • 10-30% of Interval Cancers are Related to an Incomplete Resection

General Technique Indications

  • Size 1-3 mm: Cold Forceps
  • Size < 10 mm: Cold Snare
  • Size 1-2 cm: Hot Snare
  • Size ≥ 2 cm: Controversial (EMR or ESD)
    • May Require Surgical Resection

Techniques

  • Forceps Polypectomy
    • Cold Forceps Polypectomy
      • Forceps Used to Grasp the Polyp & Pulled to Excise
      • Minor Bleeding Can Obscure View, Increasing Risk of Leaving Residual Polyp Tissue
      • Almost Negligible Risk of Colonic Perforation
    • Hot Forceps Polypectomy
      • Only the Tip of the Polyp is Grasped & Electrocautery is Used to Destroy the Polyp Base
      • Fallen Out of Favor – Similar Residual Polyp Risk as Cold Forceps Polypectomy
  • Snare Polypectomy
    • A Self-Contained Metal Ring Used to Entrap & Resect a Polyp
    • Can Be “Cold” or “Hot” (Application of Electrocautery)
  • Endoscopic Mucosal Resection (EMR)
    • Removes Polyp in Piecemeal Fashion
    • More Common in the US
  • Endoscopic Submucosal Dissection (ESD)
    • En Bloc Resection of a Mucosal Lesion with a Margin of Normal Mucosa & Some of the Submucosa
    • Enables Better Pathologic Evaluation
    • May Constitute Definitive Treatment & Avoid Colectomy
    • More Common in the East/Japan

Adjuncts

  • Mucosal Lift
    • Injection of Saline or Other Solution into the Submucosal Layer Before Polyp Resection/Dissection
    • Thickens Bowel Wall to Decrease Risk of Perforation
    • Issues:
      • Difficulty in Penetrating Mucosa May Lead to Deeper Injection (Muscularis Propria or Subserosal Layers)
      • Fluid May Leak Through Needle Puncture Holes Decreasing the Lift Throughout the Procedure
  • Endoscopic Tattooing
    • Considered for Large or Suspicious Polyps
    • Creates Easier Future Localization During Repeat Endoscopy or at Surgery
    • Generally Done in Either a 2-Quadrant or 4-Quadrant Manner to Better Localize
    • If Unable to Find Tattoo at Time of Surgery: Preform Repeat Colonoscopy Intraoperatively

Repeat Colonoscopy Recommendations