2. Introduction
• Primary aim of polypectomy
•Complete and safe removal of the colorectal lesion
•Prevention of CRC
• Removal of adenomas during colonoscopy – up to 50%
reduction in CRC mortality
• Cost effective, decreased morbidity and mortality
• Recommendations to optimize complete and safe
endoscopic removal techniques for colorectal lesions
3. Lesion Description
• Documentation of polyp
1. Location
2. Size in millimetres
3. Morphology – Paris classification, Nice
classification
4. Procedure
5. Photo documentation of the lesion before
and after removal
4. Lesion Assessment
• The Paris classification of superficial neoplasia should be used
for morphologic classification in combination with surface
topography (granular or nongranular).
• Focal interrogation by narrow band imaging to assess the
surface pit pattern according to the Kudo classification and
the vascular patterns according to the Sano classification or
more recently the Narrow-Band Imaging International
Colorectal Endoscopic (NICE) criteria.
6. • Tubular adenomas typically have large or elongated pits
(Kudo type III) and an organized brown capillary network
surrounding the pits (Sano type 2/NICE type 2).
• Villous adenomas have more complex branching gyrus like
pits (Kudo type IV).
• Submucosal invasive cancer is suspected when irregularly
mixed types or nonstructural or absent pits are present
(Kudo type V), or when irregular complex branching
capillaries or avascular areas are seen (Sano type 3/NICE
type 3).
7.
8. 1. Leave hyperplastic diminutive lesions of the rectum and
sigmoid colon.
2. Remove all adenomas anywhere in the colon and any
serrated lesions proximal to sigmoid colon and >5mm.
3. Biopsy and refer to surgery for lesions with deep
submucosal invasion.
9. Predictors of submucosal invasion
Paris classification 0-IIc
NICE type 3
Kudo pit pattern V
Redness
Firmness
Fold convergence
Non lifting sign
10. ENDOSCOPIC REMOVAL TECHNIQUES
Diminutive polyps (≤ 5 mm)
• Recommend cold snare polypectomy
• Recommend against the use of cold forceps polypectomy
(incomplete resection: 9 to 61%)
• For diminutive polyps ≤ 2 mm, Jumbo or large capacity forceps
polypectomy may be considered
• Recommend against the use of hot biopsy forceps polypectomy
• Mostly benign
• High grade
dysplasia/cancer: 0.06%
11. • Recommend cold snare polypectomy
• Recommend against the use of hot biopsy
forceps polypectomy.
Cold snare polypectomy
Less injury to submucosal arteries
Decreased risk of delayed bleeding and perforation
Small lesions (6 – 9 mm)
12. Pedunculated lesions
• Recommend hot snare polypectomy for lesions ≥ 10 mm
• Recommend prophylactic mechanical ligation of the stalk
with a detachable loop or clips on pedunculated lesions
with head ≥ 20 mm or with stalk thickness ≥ 5 mm to
reduce immediate and delayed post-polypectomy
bleeding
• Suggest retrieval of large pedunculated polyp specimens
en bloc .
13. Non-pedunculated (10–19
mm) lesions
• Suggest hot or Cold Snare polypectomy (conditional
recommendation)
• EMR should be considered for non-polypoid and
serrated lesions
Recurrence rate
3.6% by EMR
31% by conventional polypectomy
Rao et al. Clin Gastroenterol
Hepatol 2016
15. Recommended Endoscopic Equipment
for Colonic EMR
• Colonoscope
• Co2 insufflation :- CO2 significantly reduces post procedural
admissions for pain during colonic EMR.
• Microprocessor-controlled electrosurgical generators with
Snare excision - Endocut Q effect 3
• Colloid solution for submucosal injection:- Succinylated gelatin
ie. Gelofusine
• Inert dye :- 80 mg indigo carmine or 20 mg methylene blue in
500 mL solution.
16. • Adrenaline :- 1:1,00,000
• Interject :-
• Snares :- Stiff 20- or 15-mm snares with a braided wire
are preferred for en bloc and piecemeal EMR,
respectively.
• Coagulating forceps are used for more severe bleeding
or if snare tip soft coagulation fails after 2-3 attempts.
18. Resection Technique:
• EMR is a multistep process
• Optimize your access and secure a good endoscopic position
with a shortened, straight, and relaxed endoscope.
• Position the lesion at 6 o’clock in the endoscopic field.
19. • Position the patient in a way that any fluid or resected
specimens accumulate away from the lesion.
• Formulate a resection strategy; ideally, commence in the least
accessible area.
• An uncomplicated inject and resect piecemeal EMR is then
typically composed of 3 steps which are performed
repetitively: injection, 1–3 snare excisions, and then
inspection of the mucosal defect.
20. • A good injection should be dynamic and elevate the tissue
into the lumen and toward the colonoscope.
• For piecemeal EMR, start at 1 edge of the lesion and try to
include a 2- to 3-mm margin of normal mucosa.
• Use the edge of the advancing mucosal defect as a
convenient step for the next snare placement to reduce the
risk of adenoma islands.
21. • En bloc snare excision is appropriate for lesions up to 20–25
mm and is associated with lower rates of recurrence
compared with piecemeal resection.
• Thermal ablative techniques (argon plasma coagulation) to
treat visible residual adenoma should be avoided as this is
associated with high rates of recurrence.
• Complete snare excision should be the goal.
22. • After each resection, the mucosal defect should be cleaned
with the colonoscope fluid jet to ensure no adenoma islands
remain and to exclude deep mural injury.
23. Inject and cut technique
Lesions < 20 mm can be
removed in a single piece
≥ 20 mm more typically require
piecemeal resection
24. Complications:
• Complications during or after EMR are inevitable with any
significant procedural volume and to some extent predictable;
however, they are managed readily and safely if recognized
early.
• Bleeding is the most common complication and can be
categorized as intraprocedural bleeding (IPB) or delayed
bleeding.
• IPB occurs in up to 11% during EMR, is rarely serious and
readily amenable to endoscopic hemostasis.
25. • Risk factors for IPB include larger lesions, Paris 0-IIa + Is
morphology, villous or tubulovillous histology, and
procedures performed at lower volume centers.
• IPB can be treated safely and effectively with snare tip soft
coagulation.
• Coagulation forceps can be used in more severe cases, for
example, pulsatile bleeding or when snare tip soft
coagulation fails.
• Clinically significant postendoscopic resection bleeding
occurs in up to 7% of patients after colonic EMR.
26. • Most bleeding episodes occur within the first 48 hours after resection
and 60% settle with supportive care only.
• Endoscopic intervention is required for ongoing or recurrent bleeding
or those with unresponsive shock, and is usually effective.
• Rarely, angiography or surgery are needed.
• Measures to reduce the risk of clinically significant postendoscopic
resection bleeding, such as prophylactic coagulation of nonbleeding
vessels in the post-EMR mucosal defect or prophylactic clip closure of
the defect, have been neither consistently successful nor cost
effective thus far.
27. Perforation
• Perforation occurs in 1%–2% of colonic EMR and is readily
managed by endoscopic clip closure when recognized
intraprocedurally.
• True MP injury is manifested by nonstaining, often surface
disrupted areas within the relatively homogeneous “blue
mat” of the post-EMR defect or by the appearance of a“target
sign.
• Risk factors for deep mural injury were transverse colon
location (OR, 3.55), en bloc excision (OR, 3.84), and the
presence of high-grade dysplasia or invasive cancer (OR, 2.97).
28.
29.
30. • Topical submucosal chromoendoscopy can be used to
improve detection of MP injury.
• With this technique, dye is flushed on the mucosal defect
surface.
• Poorly staining areas suspicious for deep injury are recognized
and treated by clip closure.
• Full thickness perforation always warrants immediate
treatment, which can usually be readily achieved with clip
closure.
31. Recurrence
• Recurrence after colonic EMR ranges from 10% to 30% and is
considered the greatest drawback of EMR, particularly piecemeal
EMR.
• Long-term data from the ACE (Australian Colonic Endoscopic
Resection) study demonstrates that recurrences are usually small,
unifocal, and easily treated during surveillance endoscopy.
• If the initial EMR was successful, then >95% of patients are free of
adenoma during long-term followup.
• To ensure such results, a meticulous technique at the initial EMR
and a structured surveillance regimen, with colonoscopy and scar
examination at intervals of 6 and then 12 months is necessary.
32. • Risk factors for recurrence include lesion size >40 mm,
piecemeal resection, and the presence of high-grade
dysplasia.
33. Post polypectomy electrocoagulation
syndrome and delayed
perforation
• PPES is defined as an injury to the bowel wall that makes a
deep burn and contained peritonitis causing a serosal
inflammation.
• The incidence of PPES varies between 0 and 7.6% but most of
the studies report around 1%.
• The typical presentation may be limited abdominal pain, fever
and peritoneal signs associated with increased level of C-
reactive protein, leukocytosis in lab investigations and
absence of perforation on radiologic imaging.
34. • Polyp size >20 mm, right sided EMR, hypertension and
nonpolypoid lesion morphologies are the major risk factors
for PPES.
• Patients may present within few hours to 7 days after the
EMR.
• Most of the time the treatment is conservative like bowel
rest, antibiotics and use of intravenous fluids.
• Most patients improve within 24 h without any
consequences.
35. Postprocedural Care
• Patients undergoing colonic EMR require close monitoring after the
procedure
• uncomplicated cases should be monitored for 2–3 hour in the endoscopy
unit and then discharge on a clear fluid diet for an additional 12 hours
overnight.
• First surveillance colonoscopy is performed 5–6 months after the index
procedure to assess the scar area for any residual/ recurrent tissue.
• Second surveillance is performed after an additional 12 months
