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Ass Pr J Boujaoude LSGE 2012 MANAGEMENT OF LARGE COLONIC POLYPS

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Ass Pr J BoujaoudeLSGE 2012

MANAGEMENT

OF

LARGE COLONIC POLYPS

Ass Pr J BoujaoudeLSGE 2012

MANAGEMENT

OF

DIFFICULT COLONIC POLYPS

DEFINITION

DIFFICULT:

Larger than 15mm

Large pedicule

Flat and extended

Angulated

Management of large colonic polyps

SLGE 2000

Management of large colonic polyps

SLGE 2000

SURGERY• polyp extending more than 1/3 of the luminal

circumference,

• extending more than two folds

• location on the ileocecal valve,

• large, flat villous tumors

Management of large colonic polyps

LSGE 2012Advanced polypectomy techniques

We have entered an era of grey-zones

with the exception of giant polyps located in the

cecum, the majority of colonic polyps can be

resected endoscopically

LARGE

LARGE POLYPS?

SIZE:

1CM?

1.5CM?

>2CM:

<3CM?

<4CM?

LARGE POLYPS

SIZE:

1CM?

1.5CM?

LARGE >2CM:

<3CM?

< 4CM?:

>5CM? :

LARGE POLYPS

SIZE:

1CM?

1.5CM?

LARGE

>2CM:

<3CM?

< 4CM?: VERY LARGE

5CM? : GIANT

RISK?BLEEDING:

2.1% to 9%

Pedunculated polyps have feeding artery running through the pedicle

(stalk).

PERFORATION:

2.3%

LOCAL RECURRENCE:

13.4%

Most recurrences occur within the first 6 mo

Several risk factors : piecemeal resection, lesion size, and a lesion

location at the bottom of the rectum attaining the pectineal line.

PEDICULE OR

SESSILE

PEDICULE OR

SESSILE

“I see and then resect”.

CHROMOENDOSCOPY

METHODSREAL: include

contrast (e.g., indigo carmine) and

vital dyes or stains (e.g., methylene blue).

CHROMOENDOSCOPY

METHODSREAL: include

contrast (e.g., indigo carmine) and

vital dyes or stains (e.g., methylene blue).

VIRTUAL: avoid the use of dye spray and allow enhancing

the mucosal (pit pattern) and submucosal capillary network

narrow band imaging,

“Fujinon intelligent chromoendoscopy” or Fujinon-enhanced color

enhancement (FICE) or

Iscan.

Katagiri et al Current Opinion in Gastroenterology 2011

A clear-cut pre-operative diagnosis is still not clear.

POLYPECTOMY METHODS

PEDUNCULATED POLYPS

PEDUNCULATED POLYPS

Stalk:

Thin or thick

Long or short

Three endoscopic methods to resect:

Clipping the stalk

Endoloop

Injection with or without adrenaline

INJECTION

Epinephrine-saline mixture injected to the stalk of pedunculated polyp

induced;

1. mechanical compression of the feeding vessel in

the stalk by the fluid and

2. vasoconstrictive effect by epinephrine, reducing

the IPPB risk after snare resection of the stalk.

3. IPPB risk as high as 1.8% to 9.3%

Patients undergoing endoscopic resection of pedunculated polyp with distinct stalk were included

in the study, if

1) the size of the pedunculated polyp head is ≥10 mm;

2) 2) the diameter of the stalk is ≥5 mm; and

3) 3) the length of the stalk is ≥5 mm.

ENDOLOOP

SESSILE LARGE POLYP

0.8-5.2%

ENDOSCOPIC RESECTION:

- EMR

- ESD

EMR

Endoscopic Mucosal Resection

Today, EMR is the treatment of choice for sessile and flat colorectal

lesions.

the ‘inject and cut’ technique is the most

frequently used and most applicable in the

colon

into the submucosa, to create a fluid cushion between the lesion and

the muscular layer of the intestinal wall before removal of the lesion.

INJECTION OF SOLUTIONS

SOLUTIONS:

Normal saline solution with or without epinephrine.

sodium hyaluronate,

glycerol and 50% dextrose .

Indigo carmine are often added to the injectant to provide a blue-

green color to the submucosa to help in the assessment of depth

during and after resection.

Katsinelos et al. Gastrointest Endosc 2008; 68: 692–698.

Hurlstone et al. Endoscopy 2008; 40: 110–114.

EMR cap-assisted

EMRen-bloc resection was achieved with EMR in 62.85% of

lesions

Piecemeal polypectomy

There are no specific size recommendations for piecemeal

polypectomy.

Piecemeal polypectomy is recommended for sessile or flat polyps larger

than 20 mm.

it is recommended to start at the resection at the proximal end of the

polyp and to finish distally.

For very large polyps there are no set rules on how many pieces of

polyp

Local recurrence: 12.2%

“Oncologic” Colorectal Resection

tumor-free vertical and lateral margins were achieved in 58.6%.

ESD

Theoretically ESD results in a high en bloc (i.e., intoto) resection rates.

requires a high level of skill and long procedure time,

sometimes up to four or five hours.