Endoscopic Removal of Colorectal Lesions

Publication Date: February 11, 2020

Key Points

Key Points

Abbreviations, Terms, and Definitions

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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...

...ion Assessment and Descr...

...macroscopic characterization of a lesion provides...

The AGA recommends the documentation of endos...

...e AGA suggests the use of the Paris classi...

...AGA suggests that, for non-pedunculate...

...GA recommends photo documentation of all les...

The AGA suggests proficiency in the use of el...

...recommends proficiency in the endoscop...


Lesion Remova...

...he primary aim of polypectomy is complete remo...

...e (≤5mm) and small (6–9mm) Lesions...

...recommends cold snare polypectomy to remove di...

...ommends against the use of cold forceps...

...ecommends against the use of hot biopsy forceps fo...

...(10–19mm) LesionsThe AGA suggests col...

...edunculated (≥20mm) Lesions

...nds EMR as the preferred treatment me...

...commends an endoscopist experienced in advanced po...

...e AGA recommends snare resection of all gro...

...ts the use of a contrast agent, such as indigo...

...ds against the use of tattoo, using ste...

...the use of a viscous injection solution (eg,...

...GA recommends against the use of ablative t...

...he AGA suggests the use of adjuvan...

...recommends detailed inspection of the post-resecti...

...gests prophylactic closure of resection defects...

...A suggests treatment of intraproce...

...ts that patients on anti-thrombotics who are c...

Pedunculated L...

...mmends hot snare polypectomy to remove peduncula...

The AGA recommends prophylactic mechanica...

...he AGA suggests retrieval of large...

Lesion Mark...

...he AGA recommends the use of tattoo, u...

...e AGA suggests placing the tattoo at 2–3 separa...

...ggests endoscopists and surgeons establish...

...AGA recommends documentation of the details of th...


...veillance...

...e AGA recommends intensive follow-up sc...

...ssess for local recurrence, we sugg...

...n surveillance cases with suspected local r...

...n addition to detailed inspection of the post-muco...


...uipmentThe AGA recommends the use of ca...

...the use of microprocessor-controll...


...uality of Polypecto...

...e majority of benign colorectal lesion...

...n endoscopist encounters a suspected...

...e AGA suggests the documentation of the type of re...

...ommends that non-pedunculated lesio...

...unculated colorectal lesions resected e...

...ommends that endoscopists resect pedunculated l...

...mends endoscopists engage in a loca...

...ggests measuring and reporting the proportion...

...ggests the use of polypectomy compe...


...ested Electrocautery SettingªHaving tro...


...Endoscopic Classification of Superficial Neop...


...ure 2. Lateral Spreading LesionsNon-polypoid l...


...ptical Diagnosis of Colorectal Lesions, NICE C...


...hologic Features of Sessile Serrated Lesion...


...ld Polypectomy Technique(A) Diminutive col...


Figure 6. Inject-and-cut EMR(A) Evaluate a 15mm...


...7. Dynamic Submucosal Injection Technique(A) Evalu...


...e 8. Non-lifting Features of Colon...


...igure 9. Hybrid ESD of Prior Incomplete Polyp...


...d ESD of Distal Rectal Lesion Involving An...


.... Use of Retroflexion for Complete EMR(A...


Figure 12. Pedunculated Lesion with Prophylactic...


...leb Technique for Tattooing(A) A clip is visibl...


...4. Management of Colorectal LesionsVisit gastr...