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
Treatme...
...essment and Description...
...oscopic characterization of a lesion provide...
...AGA recommends the documentation of endoscopic de...
...ests the use of the Paris classificatio...
...suggests that, for non-pedunculate...
The AGA recommends photo documentation of a...
...ts proficiency in the use of electro...
...A recommends proficiency in the endoscopic recog...
Lesion Removal
...primary aim of polypectomy is comp...
...nutive (≤5mm) and small (6–9mm) Lesions...
...mmends cold snare polypectomy to remove diminuti...
...ends against the use of cold force...
The AGA recommends against the use of ho...
...ted (10–19mm) LesionsThe AGA suggests...
...nculated (≥20mm) Lesions...
...mmends EMR as the preferred treatment...
...A recommends an endoscopist experie...
...mmends snare resection of all gross...
...uggests the use of a contrast agent,...
...ds against the use of tattoo, using sterile car...
...he AGA suggests the use of a viscous injection s...
...ommends against the use of ablative techniques (...
...suggests the use of adjuvant therma...
...ecommends detailed inspection of the p...
...he AGA suggests prophylactic closure of res...
...AGA suggests treatment of intraprocedure b...
...AGA suggests that patients on anti-thromboti...
...edunculated Le...
...A recommends hot snare polypectomy to remove pedun...
...mends prophylactic mechanical ligation of...
...ests retrieval of large pedunculated polyp specim...
...ion Marking...
...GA recommends the use of tattoo, using ster...
...he AGA suggests placing the tattoo at 2–3 separa...
...AGA suggests endoscopists and surgeons est...
...commends documentation of the details of the tatt...
Surveill...
...ecommends intensive follow-up schedul...
...assess for local recurrence, we suggest care...
...n surveillance cases with suspected local re...
...on to detailed inspection of the post-mucosectomy...
EquipmentThe AGA recommends the use of carb...
...ests the use of microprocessor-cont...
...y of Polypectomy...
The majority of benign colorectal lesions ca...
...an endoscopist encounters a suspected be...
...suggests the documentation of the t...
...nds that non-pedunculated lesions...
...lated colorectal lesions resected en bloc wi...
...ommends that endoscopists resect pedunc...
...GA recommends endoscopists engage in a local (in...
...AGA suggests measuring and reporting the...
...e AGA suggests the use of polypectomy com...
...Suggested Electrocautery SettingªHa...
...igure 1. Paris Endoscopic Classifica...
...2. Lateral Spreading LesionsNon-polypo...
...Optical Diagnosis of Colorectal Lesions,...
...gure 4. Morphologic Features of Sessile Se...
...d Polypectomy Technique(A) Diminut...
...Inject-and-cut EMR(A) Evaluate a 1...
...ic Submucosal Injection Technique(A)...
.... Non-lifting Features of Colon Les...
...id ESD of Prior Incomplete Polypectomy(A)...
...igure 10. Hybrid ESD of Distal Rectal...
...of Retroflexion for Complete EMR(A) A no...
...ure 12. Pedunculated Lesion with Prophylactic Lo...
...igure 13. The Bleb Technique for Tattooing(A) A...
...gement of Colorectal LesionsVisit gast...