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
...Treatment...
...Lesion Assessme...
...croscopic characterization of a lesion pr...
...ommends the documentation of endoscopic descriptor...
...e AGA suggests the use of the Paris classif...
...e AGA suggests that, for non-peduncula...
The AGA recommends photo documentati...
The AGA suggests proficiency in th...
...GA recommends proficiency in the endoscopi...
...Lesion Removal...
...y aim of polypectomy is complete removal of the...
...Diminutive (≤...
...GA recommends cold snare polypectomy to remove di...
The AGA recommends against the use of cold force...
The AGA recommends against the use of hot b...
...nculated (10–19mm) LesionsThe AGA suggests c...
...Non-pedunculated...
...nds EMR as the preferred treatment metho...
...ecommends an endoscopist experienced...
...nds snare resection of all grossly visi...
...gests the use of a contrast agent, such as indi...
...ds against the use of tattoo, using...
...s the use of a viscous injection solut...
...ends against the use of ablative technique...
...the use of adjuvant thermal ablation of the p...
...ecommends detailed inspection of the post...
...sts prophylactic closure of resection...
...ests treatment of intraprocedure b...
...suggests that patients on anti-thrombo...
...Pe...
...A recommends hot snare polypectomy to...
...AGA recommends prophylactic mechanica...
...suggests retrieval of large peduncula...
...Lesion M...
The AGA recommends the use of tattoo, using ste...
...uggests placing the tattoo at 2–3 separate site...
...he AGA suggests endoscopists and sur...
...e AGA recommends documentation of the d...
...Surveillance...
...e AGA recommends intensive follow-up schedule in p...
...ess for local recurrence, we suggest careful...
...surveillance cases with suspected local re...
...o detailed inspection of the post-mucosec...
...A recommends the use of carbon dioxide insufflatio...
...GA suggests the use of microprocessor...
...ajority of benign colorectal lesions can...
...copist encounters a suspected benign colorectal le...
...AGA suggests the documentation of t...
The AGA recommends that non-peduncula...
...pedunculated colorectal lesions resec...
...nds that endoscopists resect pedunculated lesion...
The AGA recommends endoscopists engage in...
...gests measuring and reporting the proportion o...
...sts the use of polypectomy competency as...
...sted Electrocautery Settingª...
...e 1. Paris Endoscopic Classification of Superfi...
...l Spreading Lesions Non-polypoid lesions 1...
...e 3. Optical Diagnosis of Colorectal Lesions, N...
...Morphologic Features of Sessile Serrated Lesio...
...ure 5. Cold Polypectomy Technique (A) Dimi...
Figure 6. Inject-and-cut EMR (A) Evaluate a 1...
Figure 7. Dynamic Submucosal Inject...
...fting Features of Colon Lesions Injectio...
...Hybrid ESD of Prior Incomplete Polypectomy (A) A p...
...id ESD of Distal Rectal Lesion Involving Anal...
...e 11. Use of Retroflexion for Complete EMR (A) A...
...edunculated Lesion with Prophylactic Loo...
...he Bleb Technique for Tattooing (A...
...14. Management of Colorectal Lesions Visit gas...