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...
Lesion...
...ic characterization of a lesion provides inform...
The AGA recommends the documentation of endo...
...suggests the use of the Paris classification to de...
The AGA suggests that, for non-pedunculated...
...AGA recommends photo documentation of all lesions...
...gests proficiency in the use of electronic-...
...recommends proficiency in the endoscopic...
...Lesio...
...im of polypectomy is complete removal of the c...
...recommends cold snare polypectomy to remove dimin...
...commends against the use of cold forceps poly...
The AGA recommends against the use of hot b...
...lated (10–19mm) LesionsThe AGA sugg...
...Non-pedun...
he AGA recommends EMR as the preferred treat...
...recommends an endoscopist experience...
The AGA recommends snare resection of all g...
...suggests the use of a contrast agent,...
...A recommends against the use of tatto...
...suggests the use of a viscous injection solution...
...AGA recommends against the use of abla...
...AGA suggests the use of adjuvant thermal...
...ecommends detailed inspection of the post-resec...
...sts prophylactic closure of resection defec...
...s treatment of intraprocedure bleeding u...
...suggests that patients on anti-thromb...
...Pedunculated Lesions...
...mmends hot snare polypectomy to remove pedunculat...
...commends prophylactic mechanical ligation...
...GA suggests retrieval of large peduncul...
...Lesion Marking...
...e AGA recommends the use of tattoo, us...
...e AGA suggests placing the tattoo at 2...
...ts endoscopists and surgeons establ...
...GA recommends documentation of the...
...Surveillance...
...ommends intensive follow-up schedu...
...ess for local recurrence, we suggest care...
...eillance cases with suspected local recurrence,...
In addition to detailed inspection o...
...ipmentThe AGA recommends the use o...
...suggests the use of microprocessor-controlle...
...Quality...
...f benign colorectal lesions can be safely and eff...
...oscopist encounters a suspected ben...
...uggests the documentation of the type of resec...
...mends that non-pedunculated lesions with endoscopi...
...pedunculated colorectal lesions resected e...
...AGA recommends that endoscopists resect peduncula...
The AGA recommends endoscopists engage in a lo...
...AGA suggests measuring and reporting the pr...
...AGA suggests the use of polypectomy competency...
...uggested Electrocautery Settingª M...
...re 1. Paris Endoscopic Classification of Superfic...
...eral Spreading Lesions Non-polypoid les...
...l Diagnosis of Colorectal Lesions, NICE C...
...e 4. Morphologic Features of Sessile S...
...Cold Polypectomy Technique (A) Dimin...
...Inject-and-cut EMR (A) Evaluate a 15mm...
...Dynamic Submucosal Injection Technique (A) E...
...8. Non-lifting Features of Colon Lesi...
...d ESD of Prior Incomplete Polypectomy (...
...id ESD of Distal Rectal Lesion Involv...
...igure 11. Use of Retroflexion for Co...
...2. Pedunculated Lesion with Prophylac...
...igure 13. The Bleb Technique for Tattooing (A) A...
...ement of Colorectal Lesions Visit ga...