large colonic polyps - lsge of large colonic polyps... · • large, flat villous tumors....
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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
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.
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.
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.
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.
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%
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.