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

...eatmen...

...essment and Description...

...characterization of a lesion provides info...

...recommends the documentation of endoscopi...

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

...uggests that, for non-pedunculated adenomatous (Pa...

...e AGA recommends photo documentation of all lesion...

...AGA suggests proficiency in the use of electr...

...ecommends proficiency in the endoscopic recogniti...


Lesion Removal

...primary aim of polypectomy is complete removal...

...nutive (≤5mm) and small (6–9mm) Lesio...

...AGA recommends cold snare polypectom...

...nds against the use of cold forceps polype...

...AGA recommends against the use of hot bi...

...-pedunculated (10–19mm) LesionsThe...

...lated (≥20mm) Lesions...

...recommends EMR as the preferred treatment meth...

...GA recommends an endoscopist experienced in a...

...GA recommends snare resection of all grossly...

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

...A recommends against the use of tatt...

...suggests the use of a viscous injection solut...

...AGA recommends against the use of abla...

...ts the use of adjuvant thermal ablation of th...

...GA recommends detailed inspection of the post-res...

...GA suggests prophylactic closure of resectio...

...sts treatment of intraprocedure bleeding using e...

...sts that patients on anti-thromboti...

...ulated Lesions...

...ecommends hot snare polypectomy to remove...

...ds prophylactic mechanical ligation o...

...suggests retrieval of large pedunculate...

...on Marking...

...commends the use of tattoo, using sterile carbon p...

The AGA suggests placing the tattoo at 2–3...

...uggests endoscopists and surgeons establish a stan...

...mends documentation of the details of the tat...


Surveillan...

...he AGA recommends intensive follow-...

...r local recurrence, we suggest careful examina...

...surveillance cases with suspected local rec...

...etailed inspection of the post-mucosec...


...GA recommends the use of carbon dio...

...AGA suggests the use of microprocessor-cont...


...uality of Polypect...

...rity of benign colorectal lesions c...

...hen an endoscopist encounters a suspected...

...suggests the documentation of the type...

...e AGA recommends that non-pedunculated lesio...

...culated colorectal lesions resected en...

...e AGA recommends that endoscopists...

...ds endoscopists engage in a local (inst...

...s measuring and reporting the proportion of patien...

...he AGA suggests the use of polypectomy competency...


...sted Electrocautery SettingªHaving...


...Paris Endoscopic Classification of Superf...


...re 2. Lateral Spreading LesionsNon-po...


...gure 3. Optical Diagnosis of Colore...


...orphologic Features of Sessile Ser...


...old Polypectomy Technique(A) Diminutive co...


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


.... Dynamic Submucosal Injection Techni...


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


...Hybrid ESD of Prior Incomplete Polype...


...Hybrid ESD of Distal Rectal Lesion Involving Anal...


...f Retroflexion for Complete EMR(A) A...


...Pedunculated Lesion with Prophylac...


...13. The Bleb Technique for Tattooing...


...ure 14. Management of Colorectal LesionsVisit ga...