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Optimizing Resection of Large Colorectal Polyps

  • Colon (J Anderson, Section Editor)
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Opinion statement

Polypectomy reduces the incidence and mortality of colorectal cancer (CRC). The widespread adoption of CRC screening, more rigorous colonoscopy techniques, and advancements in endoscopic imaging have led to a greater awareness of complex polyps. Whereas surgery was once considered necessary for many large sessile or laterally spreading lesions (LSLs) in the colorectum, the majority can now be removed endoscopically. Endoscopic mucosal resection (EMR) is an established technique for treatment of colorectal LSLs. When performed by experts, EMR is highly effective and safe and can be completed in an outpatient or day-stay setting. Advancements in EMR effectiveness encompass a better understanding of the factors leading to post-EMR recurrence, protocols to recognize and treat it, and interventions that prevent recurrent or residual adenoma. New techniques for treating intra-procedural bleeding and a novel classification system to identify and inform proactive management of deep mural injury enhance the safety profile of EMR. However, each of these incremental advancements necessitates a meticulous and systematic approach that only committed and properly trained endoscopists can master. While alternative interventions such as endoscopic submucosal dissection (ESD) offer potential advantages over EMR, the added procedural complexity, risks, and costs limit the relevance of ESD to a minority of lesions in the colorectum. This article reviews the expanding body of evidence supporting EMR as the first-line treatment of colorectal LSLs ≥20 mm.

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Authors and Affiliations

  1. Department of Medicine, University of Calgary, Calgary, AB, Canada

    Steven J. Heitman MD MSc FRCPC

  2. Department of Gastroenterology and Hepatology, Westmead Hospital, c/-Suite 106a, 151-155 Hawkesbury Road, Westmead, Sydney, NSW, 2145, Australia

    David J. Tate MBBS, MA (Cantab), MRCP & Michael J. Bourke MBBS,FRACP

  3. Westmead Clinical School, University of Sydney, Sydney, NSW, Australia

    David J. Tate MBBS, MA (Cantab), MRCP & Michael J. Bourke MBBS,FRACP

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  1. Steven J. Heitman MD MSc FRCPC
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  2. David J. Tate MBBS, MA (Cantab), MRCP
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  3. Michael J. Bourke MBBS,FRACP
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Correspondence to Michael J. Bourke MBBS,FRACP.

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Conflict of interest

Steven J. Heitman, David J. Tate, and Michael J. Bourke declare that they have no conflict of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Colon

Summary box: recommendations for endoscopic mucosal resection (EMR)

Summary box: recommendations for endoscopic mucosal resection (EMR)

Fundamentals of resection:

  • Practitioners of EMR must methodically characterize all lesions and assess for features of submucosal invasion prior to commencing the resection.

  • Submucosal injection is done in a dynamic fashion using a crystalloid/colloid solution containing a dye (indigo carmine or methylene blue) and dilute epinephrine (1:100,000).

  • Snare selection (size, shape, wire thickness) is tailored to the lesion.

  • A systematic inject-and-resect technique is performed. This includes meticulous snare placement and tissue capture, snare closure by the endoscopist with a check for tissue mobility, and finally application of thermal energy controlled by a microprocessor electrosurgical unit.

  • Use of CO2 insufflation throughout the procedure is mandatory.

Prevention of recurrence:

  • All visible adenoma should be resected using a snare.

  • The resection margin should include a 1–2 mm circumferential rim of endoscopically normal tissue.

  • Following removal of all endoscopically apparent adenoma, we routinely treat the post-EMR margin with snare tip soft coagulation (ERBE Effect 4, 80 W) to treat invisible potential residual disease in an adjuvant setting.

Managing intra-procedural bleeding and addressing deep mural injury:

  • Patients should be positioned such that dependent fluid (including blood) pools away from the resection field.

  • Minor intra-procedural bleeding should be treated with snare tip soft coagulation.

  • Coagulating forceps can be used to treat persistent or significant bleeding and are preferred over endoscopic clips, which can interfere with the resection.

  • The Sydney Classification of Deep Mural Injury categorizes the full spectrum of mural injury and we use it to evaluate all post-EMR defects.

  • Topical application of the chromoinjectate using the injection catheter with the needle retracted can be used to focally interrogate areas of potential concern.

  • In 2017, tissue resection-related perforation can be reliably treated endoscopically with clip closure in >95% of cases. The key aspect is to recognize it during the procedure.

Follow-up:

  • Surveillance should occur at 4–6 months and 18 months post EMR.

  • Endoscopists must carefully and systematically evaluate all post-EMR scars using high-definition white light and virtual chromoendoscopy.

  • For endoscopically evident recurrence, we attempt to resect it using a stiff thin-wired snare. When snare excision is not feasible, we employ the technique of cold avulsion using standard biopsy forceps followed by snare tip soft coagulation.

  • Any inconclusive nodularity should be biopsied and then destroyed.

  • At present, routine biopsy of the post-EMR scar during surveillance is standard of care, but our recent evidence suggests that it may not be necessary and can be better targeted using high definition endoscopic imaging.

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Heitman, S.J., Tate, D.J. & Bourke, M.J. Optimizing Resection of Large Colorectal Polyps. Curr Treat Options Gastro 15, 213–229 (2017). https://doi.org/10.1007/s11938-017-0131-5

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