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
...ssessment and Description...
...macroscopic characterization of a lesio...
...mends the documentation of endoscopic descri...
...ts the use of the Paris classificat...
...AGA suggests that, for non-pedunculated adenomato...
...ds photo documentation of all lesions...
...suggests proficiency in the use of...
...recommends proficiency in the endoscopic recogni...
Lesion Remova...
...ry aim of polypectomy is complete removal...
...¤5mm) and small (6–9mm) Lesions...
...ds cold snare polypectomy to remove diminutive (...
...A recommends against the use of cold f...
...A recommends against the use of hot biop...
Non-pedunculated (10–19mm) LesionsThe AGA sugge...
...nculated (≥20mm) Lesion...
...e AGA recommends EMR as the preferred treatment...
...commends an endoscopist experienced in advanced...
...A recommends snare resection of all gross...
...e AGA suggests the use of a contrast agent, s...
...recommends against the use of tattoo, usi...
...he AGA suggests the use of a viscous injec...
The AGA recommends against the use of ablative...
...ggests the use of adjuvant thermal ablati...
...recommends detailed inspection of the post-r...
...A suggests prophylactic closure of resec...
...s treatment of intraprocedure bleed...
...A suggests that patients on anti-thrombotics w...
...ulated Lesions...
...e AGA recommends hot snare polypectom...
...nds prophylactic mechanical ligation...
...suggests retrieval of large pedunculated...
Lesion Marki...
...mmends the use of tattoo, using st...
...suggests placing the tattoo at 2–3 separ...
...sts endoscopists and surgeons establish a sta...
...e AGA recommends documentation of the details of...
...veillance...
...ds intensive follow-up schedule in patients...
...s for local recurrence, we suggest careful e...
...ce cases with suspected local recurrence,...
...dition to detailed inspection of the post-m...
...ipmentThe AGA recommends the use of...
The AGA suggests the use of microprocesso...
...y of Polypectomy...
...ity of benign colorectal lesions can b...
...n endoscopist encounters a suspected benign...
...suggests the documentation of the ty...
...mmends that non-pedunculated lesions with end...
...unculated colorectal lesions resected en bloc...
...recommends that endoscopists resect ped...
...mends endoscopists engage in a local (institution...
...ts measuring and reporting the pro...
...GA suggests the use of polypectomy competency ass...
...ted Electrocautery SettingªHaving trouble viewin...
...Paris Endoscopic Classification of Superficial N...
...Lateral Spreading LesionsNon-polypoid...
...Optical Diagnosis of Colorectal Lesions, N...
...Morphologic Features of Sessile Serrated Lesio...
...gure 5. Cold Polypectomy Technique(A) Dim...
...ect-and-cut EMR(A) Evaluate a 15mm superficial...
...c Submucosal Injection Technique(A...
...Non-lifting Features of Colon LesionsIn...
...igure 9. Hybrid ESD of Prior Incomplete Polypect...
...d ESD of Distal Rectal Lesion Involving...
...gure 11. Use of Retroflexion for Complete EMR(A)...
...dunculated Lesion with Prophylactic...
...13. The Bleb Technique for Tattooin...
...Management of Colorectal LesionsVisit g...