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
Treatm...
...ion Assessment and Des...
...croscopic characterization of a lesion provid...
...ommends the documentation of endoscopic de...
...the use of the Paris classification to de...
...ts that, for non-pedunculated adenomatous (Pari...
...e AGA recommends photo documentation of a...
...he AGA suggests proficiency in the us...
...mmends proficiency in the endoscopic recog...
...on Removal...
...y aim of polypectomy is complete removal of...
...5mm) and small (6–9mm) Lesions...
...mends cold snare polypectomy to remo...
...AGA recommends against the use of cold f...
...he AGA recommends against the use of hot biopsy...
...ed (10–19mm) LesionsThe AGA sugges...
...nculated (≥20mm) Lesions...
...mends EMR as the preferred treatment method of...
...e AGA recommends an endoscopist experienc...
...AGA recommends snare resection of all grossly vis...
...ests the use of a contrast agent, such as in...
...GA recommends against the use of tattoo, using...
...ts the use of a viscous injection solutio...
...ommends against the use of ablative te...
...A suggests the use of adjuvant the...
The AGA recommends detailed inspection of the po...
...AGA suggests prophylactic closure of resection...
...e AGA suggests treatment of intraprocedure b...
...e AGA suggests that patients on anti-thro...
...nculated Lesions...
...AGA recommends hot snare polypectomy t...
...nds prophylactic mechanical ligation...
...retrieval of large pedunculated polyp specimens...
...esion Markin...
...e AGA recommends the use of tattoo, using...
...AGA suggests placing the tattoo at...
...suggests endoscopists and surgeons esta...
...recommends documentation of the details of t...
...rveillanc...
...GA recommends intensive follow-up s...
...ocal recurrence, we suggest careful examination of...
In surveillance cases with suspected local recurre...
In addition to detailed inspection of the pos...
...e AGA recommends the use of carbon dioxide i...
...gests the use of microprocessor-controlled electro...
Quality of Polypec...
...ty of benign colorectal lesions can be safe...
...opist encounters a suspected benign colore...
...s the documentation of the type of resection...
...ends that non-pedunculated lesions with...
...ulated colorectal lesions resected en bloc with su...
...ds that endoscopists resect peduncul...
...mmends endoscopists engage in a local (institu...
...sts measuring and reporting the proportion o...
...AGA suggests the use of polypectomy co...
...1. Suggested Electrocautery SettingªHaving troubl...
...ure 1. Paris Endoscopic Classification of Superfic...
...igure 2. Lateral Spreading LesionsNon-p...
...tical Diagnosis of Colorectal Lesions, NICE...
...ologic Features of Sessile Serrate...
...olypectomy Technique(A) Diminutive colon l...
...re 6. Inject-and-cut EMR(A) Evaluate...
...gure 7. Dynamic Submucosal Injection Tec...
...n-lifting Features of Colon LesionsI...
...gure 9. Hybrid ESD of Prior Incomp...
...Hybrid ESD of Distal Rectal Lesion Involving An...
...ure 11. Use of Retroflexion for Com...
...Pedunculated Lesion with Prophylactic Loo...
...13. The Bleb Technique for Tattooi...
...gement of Colorectal LesionsVisit gastro.o...