Endoscopic Removal of Colorectal Lesions
Key Points
Key Points
Abbreviations, Terms, and Definitions
| Abbreviations and Terms | Definition |
|---|---|
| CRC | Colorectal cancer |
| EMR | Endoscopic mucosal resection |
| APC | Argon plasma coagulation |
| USMSTF | US Multi-Society Task Force |
| GRADE | Grading of Recommendations, Assessment, Development, and Evaluation Ratings of Evidence |
| SSP | Sessile serated polyp |
| ESD | Endoscopic submucosal dissection |
| LST | Laterally spreading tumor |
| LST-G | Laterally spreading tumor, granular |
| LST-G-H | Laterally spreading tumor, granular-homogenous |
| LST-G-NM | Laterally spreading tumor, granular-nodular mixed |
| LST-NG | Laterally spreading tumor, non-granular |
| LST-NG-FE | Laterally spreading tumor, non-granular-flat elevated |
| LST-NG-PD | Laterally spreading tumor, non-granular-pseudodepressed |
| NICE | Narrow Band Imaging International Colorectal Endoscopic |
| NBI | Narrow band imaging |
| HSP | Hot snare polypectomy |
| CARE | Complete adenoma resection |
| ASGE | American Society for Gastrointestinal Endoscopy |
| ACG | American College of Gastroenterology |
| DOPyS | Direct Observation of Polypectomy Skills |
| CSPAT | Cold Snare Polypectomy Assessment Tool |
| Diminutive | Lesion size 5mm |
| Small | Lesion size 6–9mm |
| Large | Lesion size 20mm |
| Polypoid | Lesion protrudes from mucosa into lumen, includes pedunculated and sessile. |
| Pedunculated (0–Ip) | Lesion attached to mucosa by stalk; the base of lesion is narrow. |
| Sessile (0–Is) | Lesion not attached to mucosa by stalk; the base and top of the lesion have the same diameter. |
| Non-polypoid | Lesion has little to no protrusion above the mucosa. Includes superficial elevated, flat, and depressed. |
| Superficial elevated (0-IIa) | Lesion height <2.5mm above normal mucosa, sometimes defined as height less than one-half of the lesion diameter |
| Flat (0-IIb) | Lesion without any protrusion above mucosa |
| Depressed (0-IIc) | Lesion with base that is lower than the normal mucosa |
| Laterally spreading tumor (LST) | Laterally growing superficial neoplasm (instead of upward or downward growth) 10mm in size |
| LST-granular-homogenous (LST-G-H) | LST polypoid type that corresponds to Paris subtype 0-IIa |
| LST-granular-nodular mixed (LST-G-NM) | LST type that corresponds to combination of Paris subtype 0–IIa and 0–Is LST-non-granular-flat elevated (LST-NG-FE) |
| LST-non-granular-pseudodepressed (LST-NG-PD) | LST non-polypoid type corresponds to combination of Paris subtype 0–IIa and 0–IIc |
| NICE type 1 | Serrated class includes hyperplastic and sessile serrated lesions. |
| NICE type 2 | Adenomas |
| NICE type 3 | Lesions with deep (>1000mm) submucosal invasion. |
| Cold snare polypectomy | Snare polypectomy without use of electrocautery. |
| Endoscopic mucosal resection | Technique involving injecting solution into submucosal space to separate mucosal lesion from underlying muscularis propria. Lesion can then be removed by snare. |
| Underwater EMR | Technique involving full water immersion so that mucosa and submucosa involute as folds while muscularis propria remains circular. Lesion is then resected by hot snare. |
| Endoscopic submucosal dissection | Technique involving lifting by submucosal injectant and using ESD knife to create incision around lesion’s perimeter and to dissect through expanded submucosal layer for en bloc resection. |
| Hybrid ESD | Partial submucosal dissection followed by en bloc snare resection Endoscopic full thickness resection <30mm. |
| Cold or hot avulsion | Variant of biopsy technique for resection of fibrous residual or recurrent tissue that is non-lifting or difficult to capture with a snare. The hot avulsion technique uses endocut current (not coagulation current) and pulls the tissue away in the forceps as the current is applied. |
| Argon plasma coagulation | Ablative technique requiring use of ionization of argon gas by electrocautery to prevent deep tissue injury. |
| Snare tip soft coagulation | Ablative technique requiring use of a microprocessor-controlled generator capable of delivering fixed low-voltage output, which is capped at 19 volts to prevent deep tissue injury. |
| Chromoendoscopy | Application of dye to the colon mucosa or in the submucosal injectant for contrast enhancement to improve visualization of epithelial surface detail and resection plane. |
| Intraprocedural bleeding | Bleeding that occurs during procedure requiring endoscopic intervention. |
| Post-procedural bleeding | Bleeding that occurs up to 30 d after procedure requiring clinical intervention. |
Treatment
...reatment...
...n Assessment and Descriptio...
...macroscopic characterization of a lesion provi...
...commends the documentation of endoscopic descript...
...suggests the use of the Paris clas...
...that, for non-pedunculated adenomato...
...nds photo documentation of all lesions ≥10mm...
...ests proficiency in the use of electro...
...e AGA recommends proficiency in the endoscopic...
...ion Removal...
...of polypectomy is complete removal of the co...
...utive (≤5mm) and small (6–9mm) Lesions...
...mends cold snare polypectomy to remove diminu...
...ecommends against the use of cold forceps polype...
The AGA recommends against the use of hot biopsy f...
...n-pedunculated (10–19mm) LesionsThe...
...dunculated (≥20mm) Lesions...
...e AGA recommends EMR as the preferred treat...
...recommends an endoscopist experienced in advance...
...he AGA recommends snare resection of...
The AGA suggests the use of a contras...
...ds against the use of tattoo, using s...
...suggests the use of a viscous injection s...
...GA recommends against the use of abl...
...gests the use of adjuvant thermal ab...
...AGA recommends detailed inspection...
...ts prophylactic closure of resection def...
...ests treatment of intraprocedure bleeding usi...
...AGA suggests that patients on anti-t...
...edunculated Les...
...ends hot snare polypectomy to remove p...
...ends prophylactic mechanical ligation o...
...ests retrieval of large pedunculated polyp specim...
...sion Marking
...mmends the use of tattoo, using sterile carbon pa...
...AGA suggests placing the tattoo at 2–3 separa...
...suggests endoscopists and surgeons estab...
...nds documentation of the details of the tatto...
...urveillan...
...AGA recommends intensive follow-up schedule...
...s for local recurrence, we suggest careful exami...
...e cases with suspected local recurrence, we s...
...detailed inspection of the post-mucosectom...
...ipmentThe AGA recommends the use o...
...suggests the use of microprocessor-c...
...of Polypectomy...
...rity of benign colorectal lesions can be...
...endoscopist encounters a suspected benign colo...
...ts the documentation of the type of rese...
...e AGA recommends that non-pedunculated lesions wi...
For non-pedunculated colorectal le...
...nds that endoscopists resect pedunculated...
...mmends endoscopists engage in a local (...
...AGA suggests measuring and reporting the proporti...
...uggests the use of polypectomy comp...
Table 1. Suggested Electrocautery SettingªHa...
...e 1. Paris Endoscopic Classification of...
...l Spreading LesionsNon-polypoid lesions 1...
...ptical Diagnosis of Colorectal Lesions, NICE...
...e 4. Morphologic Features of Sessile Serr...
...5. Cold Polypectomy Technique(A) Diminutive colo...
...ect-and-cut EMR(A) Evaluate a 15mm superficially...
...Dynamic Submucosal Injection Technique(A) Evaluate...
...n-lifting Features of Colon LesionsInjection...
...9. Hybrid ESD of Prior Incomplete Polypecto...
...igure 10. Hybrid ESD of Distal Rectal L...
...11. Use of Retroflexion for Complete EMR(A) A non...
...gure 12. Pedunculated Lesion with P...
...igure 13. The Bleb Technique for T...
...Management of Colorectal LesionsVisit...