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
...atment...
Lesion Assessment and De...
...macroscopic characterization of a lesi...
...A recommends the documentation of endos...
...suggests the use of the Paris classificatio...
...GA suggests that, for non-pedunculated...
...commends photo documentation of all lesions â...
...suggests proficiency in the use of electronic- (...
...he AGA recommends proficiency in the endoscopi...
Lesion Remova...
...imary aim of polypectomy is complete remova...
...ve (≤5mm) and small (6–9mm) Le...
...recommends cold snare polypectomy to r...
...AGA recommends against the use of cold forcep...
...he AGA recommends against the use o...
...ulated (10–19mm) LesionsThe AGA su...
...ulated (≥20mm) Lesions...
...e AGA recommends EMR as the preferred trea...
...mends an endoscopist experienced in advanc...
...mmends snare resection of all gros...
...gests the use of a contrast agent, such as indig...
The AGA recommends against the use of...
...suggests the use of a viscous injection soluti...
...recommends against the use of ablativ...
...suggests the use of adjuvant therm...
...recommends detailed inspection of the post-res...
...he AGA suggests prophylactic closure of resection...
...suggests treatment of intraprocedure...
...sts that patients on anti-thrombotics who...
...dunculated Lesi...
...he AGA recommends hot snare polypectomy to remov...
...ecommends prophylactic mechanical ligatio...
...AGA suggests retrieval of large pedunculated pol...
...on Marking
...ds the use of tattoo, using sterile...
...AGA suggests placing the tattoo at 2–...
...AGA suggests endoscopists and surgeons...
...recommends documentation of the details of th...
Surveill...
...ommends intensive follow-up schedule in p...
...cal recurrence, we suggest careful examination...
...surveillance cases with suspected local re...
...on to detailed inspection of the post-mu...
...tThe AGA recommends the use of carb...
...A suggests the use of microprocessor-controlle...
Quality of Polypectom...
...benign colorectal lesions can be safely and e...
...scopist encounters a suspected ben...
...uggests the documentation of the type of...
...ecommends that non-pedunculated lesions with endos...
...culated colorectal lesions resected en bloc w...
...commends that endoscopists resect pedunculat...
...mends endoscopists engage in a loca...
...AGA suggests measuring and reporting...
...e AGA suggests the use of polypectomy competency a...
...le 1. Suggested Electrocautery SettingªHavi...
...Endoscopic Classification of Superficial Neop...
...teral Spreading LesionsNon-polypoid lesions...
...al Diagnosis of Colorectal Lesions, NICE Classi...
...4. Morphologic Features of Sessile Serr...
...igure 5. Cold Polypectomy Technique(A)...
...6. Inject-and-cut EMR(A) Evaluate a 15mm...
...gure 7. Dynamic Submucosal Injection Technique(A)...
...lifting Features of Colon LesionsInjection o...
...ESD of Prior Incomplete Polypectomy(A) A prior i...
...Hybrid ESD of Distal Rectal Lesion Involving Anal...
...gure 11. Use of Retroflexion for Complet...
...unculated Lesion with Prophylactic LoopingU...
...ure 13. The Bleb Technique for Tattooing(A)...
.... Management of Colorectal LesionsVisit gast...