Endoscopic removal of large colon polyps
- Uwe Seitz, MD
Uwe Seitz, MD
- Bergstrasse Medical Center, Heppenheim
- University Hospital Heidelberg, Germany
- Sabine Bohnacker, MD
Sabine Bohnacker, MD
- GRN Medical Center, Sinsheim
- Bergstrasse Medical Center, Heppenheim
- University Hospital Heidelberg, Germany
- Kenneth F Binmoeller, MD
Kenneth F Binmoeller, MD
- Associate Professor of Surgery
- California Pacific Medical Center, San Francisco
The removal of large colon polyps during endoscopy raises a number of concerns, including the risk of the procedure and the possibility of inadequate polypectomy. The latter is particularly concerning since large polyps have an increased risk of harboring invasive carcinoma [1-5]. Endoscopic resection of large polyps, especially laterally spreading sessile polyps, is also significantly more time-consuming and requires more resources compared with polypectomy of smaller lesions .
Because of these issues, surgical resection is often used, particularly for large sessile polyps and for those in locations that are difficult to treat endoscopically. However, endoscopic removal of the polyps may be possible if an endoscopist experienced in the removal of large colon polyps is available, avoiding the need for surgery [1-5,7].
This topic will review the endoscopic removal of large colon polyps. The definition of "large" varies in the literature; for the purpose of this discussion, the definition of large will refer to polyps that are ≥2.0 cm in their greatest dimension. An overview of colonoscopy and the treatment and prevention of postpolypectomy bleeding are discussed separately. (See "Overview of colonoscopy in adults" and "Bleeding after colonic polypectomy".)
Appropriate patients for endoscopic removal of large colon polyps include those in whom the concern for invasive cancer is low and the size and location of the polyp are amenable to endoscopic resection with a relatively low risk of complications. In addition, endoscopic resection may be appropriate for patients who do not meet these criteria but who are poor surgical candidates.
Features suggesting invasive cancer — Large polyps may contain cancer that is completely contained within the polyp. In these cases, polypectomy is considered curative, provided the cancer is completely contained within the resected tissue, there is no lymphovascular invasion, and the resection margins are free of cancer [8-11]. Pedunculated polyps (ie, polyps with a stalk (picture 1)) can generally be removed endoscopically, even if the polyp tissue appears malignant, provided the stalk appears normal. Sessile polyps (ie, polyps that lack a stalk (picture 2)) should only be removed endoscopically if they lack malignant features.
- Binmoeller KF, Bohnacker S, Seifert H, et al. Endoscopic snare excision of "giant" colorectal polyps. Gastrointest Endosc 1996; 43:183.
- Walsh RM, Ackroyd FW, Shellito PC. Endoscopic resection of large sessile colorectal polyps. Gastrointest Endosc 1992; 38:303.
- Doniec JM, Löhnert MS, Schniewind B, et al. Endoscopic removal of large colorectal polyps: prevention of unnecessary surgery? Dis Colon Rectum 2003; 46:340.
- Kanamori T, Itoh M, Yokoyama Y, Tsuchida K. Injection-incision--assisted snare resection of large sessile colorectal polyps. Gastrointest Endosc 1996; 43:189.
- Boix J, Lorenzo-Zúñiga V, Moreno de Vega V, et al. Endoscopic removal of large sessile colorectal adenomas: is it safe and effective? Dig Dis Sci 2007; 52:840.
- Overhiser AJ, Rex DK. Work and resources needed for endoscopic resection of large sessile colorectal polyps. Clin Gastroenterol Hepatol 2007; 5:1076.
- Moss A, Williams SJ, Hourigan LF, et al. Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut 2015; 64:57.
- Seitz U, Bohnacker S, Seewald S, et al. Is endoscopic polypectomy an adequate therapy for malignant colorectal adenomas? Presentation of 114 patients and review of the literature. Dis Colon Rectum 2004; 47:1789.
- Hackelsberger A, Frühmorgen P, Weiler H, et al. Endoscopic polypectomy and management of colorectal adenomas with invasive carcinoma. Endoscopy 1995; 27:153.
- Cranley JP, Petras RE, Carey WD, et al. When is endoscopic polypectomy adequate therapy for colonic polyps containing invasive carcinoma? Gastroenterology 1986; 91:419.
- Netzer P, Binek J, Hammer B, et al. Significance of histologic criteria for the management of patients with malignant colorectal polyps and polypectomy. Scand J Gastroenterol 1997; 32:910.
- Galandiuk S, Fazio VW, Jagelman DG, et al. Villous and tubulovillous adenomas of the colon and rectum. A retrospective review, 1964-1985. Am J Surg 1987; 153:41.
- Moss A, Bourke MJ, Williams SJ, et al. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology 2011; 140:1909.
- Tanaka S, Haruma K, Oka S, et al. Clinicopathologic features and endoscopic treatment of superficially spreading colorectal neoplasms larger than 20 mm. Gastrointest Endosc 2001; 54:62.
- Hurlstone DP, Sanders DS, Cross SS, et al. Colonoscopic resection of lateral spreading tumours: a prospective analysis of endoscopic mucosal resection. Gut 2004; 53:1334.
- Uraoka T, Kato J, Ishikawa S, et al. Thin endoscope-assisted endoscopic submucosal dissection for large colorectal tumors (with videos). Gastrointest Endosc 2007; 66:836.
- Kim BC, Chang HJ, Han KS, et al. Clinicopathological differences of laterally spreading tumors of the colorectum according to gross appearance. Endoscopy 2011; 43:100.
- Waye JD. Advanced polypectomy. Gastrointest Endosc Clin N Am 2005; 15:733.
- Kim JH, Lee HJ, Ahn JW, et al. Risk factors for delayed post-polypectomy hemorrhage: a case-control study. J Gastroenterol Hepatol 2013; 28:645.
- Buddingh KT, Herngreen T, Haringsma J, et al. Location in the right hemi-colon is an independent risk factor for delayed post-polypectomy hemorrhage: a multi-center case-control study. Am J Gastroenterol 2011; 106:1119.
- Soehendra N, Binmoeller KF, Seifert S, et al. Therapeutic Endoscopy, 1st Ed, Thieme Verlag, Hamburg, New York 1998.
- Kaltenbach T, Soetikno R. Endoscopic resection of large colon polyps. Gastrointest Endosc Clin N Am 2013; 23:137.
- Bardan E, Bat L, Melzer E, et al. Colonoscopic resection of large colonic polyps--a prospective study. Isr J Med Sci 1997; 33:777.
- Kudo S. Early colorectal cancer, 1st Ed, Igaku-Shoin, Tokyo 1996. p.15.
- Iishi H, Tatsuta M, Iseki K, et al. Endoscopic piecemeal resection with submucosal saline injection of large sessile colorectal polyps. Gastrointest Endosc 2000; 51:697.
- Shirai M, Nakamura T, Matsuura A, et al. Safer colonoscopic polypectomy with local submucosal injection of hypertonic saline-epinephrine solution. Am J Gastroenterol 1994; 89:334.
- Yoshida N, Naito Y, Inada Y, et al. Endoscopic mucosal resection with 0.13% hyaluronic acid solution for colorectal polyps less than 20 mm: a randomized controlled trial. J Gastroenterol Hepatol 2012; 27:1377.
- Friedland S, Kothari S, Chen A, et al. Endoscopic mucosal resection with an over-the-counter hyaluronate preparation. Gastrointest Endosc 2012; 75:1040.
- Katsinelos P, Kountouras J, Paroutoglou G, et al. A comparative study of 50% dextrose and normal saline solution on their ability to create submucosal fluid cushions for endoscopic resection of sessile rectosigmoid polyps. Gastrointest Endosc 2008; 68:692.
- Moss A, Bourke MJ, Metz AJ. A randomized, double-blind trial of succinylated gelatin submucosal injection for endoscopic resection of large sessile polyps of the colon. Am J Gastroenterol 2010; 105:2375.
- Fasoulas K, Lazaraki G, Chatzimavroudis G, et al. Endoscopic mucosal resection of giant laterally spreading tumors with submucosal injection of hydroxyethyl starch: comparative study with normal saline solution. Surg Laparosc Endosc Percutan Tech 2012; 22:272.
- Lee SH, Chung IK, Kim SJ, et al. Comparison of postpolypectomy bleeding between epinephrine and saline submucosal injection for large colon polyps by conventional polypectomy: a prospective randomized, multicenter study. World J Gastroenterol 2007; 13:2973.
- Rex DK, Khashab M. Colonoscopic polypectomy in retroflexion. Gastrointest Endosc 2006; 63:144.
- Toyonaga T, Man-I M, Morita Y, et al. The new resources of treatment for early stage colorectal tumors: EMR with small incision and simplified endoscopic submucosal dissection. Dig Endosc 2009; 21 Suppl 1:S31.
- Sakamoto N, Osada T, Shibuya T, et al. Endoscopic submucosal dissection of large colorectal tumors by using a novel spring-action S-O clip for traction (with video). Gastrointest Endosc 2009; 69:1370.
- Yahagi N, Neuhaus H, Schumacher B, et al. Comparison of standard endoscopic submucosal dissection (ESD) versus an optimized ESD technique for the colon: an animal study. Endoscopy 2009; 41:340.
- Fujishiro M, Yahagi N, Nakamura M, et al. Successful outcomes of a novel endoscopic treatment for GI tumors: endoscopic submucosal dissection with a mixture of high-molecular-weight hyaluronic acid, glycerin, and sugar. Gastrointest Endosc 2006; 63:243.
- Tanaka S, Oka S, Kaneko I, et al. Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization. Gastrointest Endosc 2007; 66:100.
- Repici A, Conio M, De Angelis C, et al. Insulated-tip knife endoscopic mucosal resection of large colorectal polyps unsuitable for standard polypectomy. Am J Gastroenterol 2007; 102:1617.
- Shioji K, Suzuki Y, Kobayashi M, et al. Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy. Gastrointest Endosc 2003; 57:691.
- Church JM. Experience in the endoscopic management of large colonic polyps. ANZ J Surg 2003; 73:988.
- Liaquat H, Rohn E, Rex DK. Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions. Gastrointest Endosc 2013; 77:401.
- Hsieh YH, Lin HJ, Tseng GY, et al. Is submucosal epinephrine injection necessary before polypectomy? A prospective, comparative study. Hepatogastroenterology 2001; 48:1379.
- Dobrowolski S, Dobosz M, Babicki A, et al. Prophylactic submucosal saline-adrenaline injection in colonoscopic polypectomy: prospective randomized study. Surg Endosc 2004; 18:990.
- Di Giorgio P, De Luca L, Calcagno G, et al. Detachable snare versus epinephrine injection in the prevention of postpolypectomy bleeding: a randomized and controlled study. Endoscopy 2004; 36:860.
- Paspatis GA, Paraskeva K, Theodoropoulou A, et al. A prospective, randomized comparison of adrenaline injection in combination with detachable snare versus adrenaline injection alone in the prevention of postpolypectomy bleeding in large colonic polyps. Am J Gastroenterol 2006; 101:2805; quiz 2913.
- Matsushita M, Hajiro K, Takakuwa H, et al. Ineffective use of a detachable snare for colonoscopic polypectomy of large polyps. Gastrointest Endosc 1998; 47:496.
- Hassan C, Repici A, Sharma P, et al. Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut 2016; 65:806.
- Swan MP, Bourke MJ, Alexander S, et al. Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos). Gastrointest Endosc 2009; 70:1128.
- Arebi N, Swain D, Suzuki N, et al. Endoscopic mucosal resection of 161 cases of large sessile or flat colorectal polyps. Scand J Gastroenterol 2007; 42:859.
- Rao AK, Soetikno R, Raju GS, et al. Large Sessile Serrated Polyps Can Be Safely and Effectively Removed by Endoscopic Mucosal Resection. Clin Gastroenterol Hepatol 2016; 14:568.
- Saito Y, Fukuzawa M, Matsuda T, et al. Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection. Surg Endosc 2010; 24:343.
- Tamegai Y, Saito Y, Masaki N, et al. Endoscopic submucosal dissection: a safe technique for colorectal tumors. Endoscopy 2007; 39:418.
- Khashab M, Eid E, Rusche M, Rex DK. Incidence and predictors of "late" recurrences after endoscopic piecemeal resection of large sessile adenomas. Gastrointest Endosc 2009; 70:344.
- Luigiano C, Consolo P, Scaffidi MG, et al. Endoscopic mucosal resection for large and giant sessile and flat colorectal polyps: a single-center experience with long-term follow-up. Endoscopy 2009; 41:829.
- Zlatanic J, Waye JD, Kim PS, et al. Large sessile colonic adenomas: use of argon plasma coagulator to supplement piecemeal snare polypectomy. Gastrointest Endosc 1999; 49:731.
- Brooker JC, Saunders BP, Shah SG, et al. Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations. Gastrointest Endosc 2002; 55:371.
- Conio M, Repici A, Demarquay JF, et al. EMR of large sessile colorectal polyps. Gastrointest Endosc 2004; 60:234.
- Fujiya M, Tanaka K, Dokoshi T, et al. Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection. Gastrointest Endosc 2015; 81:583.
- Oka S, Tanaka S, Saito Y, et al. Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan. Am J Gastroenterol 2015; 110:697.
- Stergiou N, Riphaus A, Lange P, et al. Endoscopic snare resection of large colonic polyps: how far can we go? Int J Colorectal Dis 2003; 18:131.
- Puli SR, Kakugawa Y, Saito Y, et al. Successful complete cure en-bloc resection of large nonpedunculated colonic polyps by endoscopic submucosal dissection: a meta-analysis and systematic review. Ann Surg Oncol 2009; 16:2147.
- Kim HG, Thosani N, Banerjee S, et al. Effect of prior biopsy sampling, tattoo placement, and snare sampling on endoscopic resection of large nonpedunculated colorectal lesions. Gastrointest Endosc 2015; 81:204.
- Pellise M, Burgess NG, Tutticci N, et al. Endoscopic mucosal resection for large serrated lesions in comparison with adenomas: a prospective multicentre study of 2000 lesions. Gut 2016.
- Burgess NG, Metz AJ, Williams SJ, et al. Risk factors for intraprocedural and clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol 2014; 12:651.
- Huang C, Huang RX, Xiang P, Qiu ZJ. Current research status of endoscopic submucosal dissection for colorectal neoplasms. Clin Invest Med 2012; 35:E158.
- Swan MP, Bourke MJ, Moss A, et al. The target sign: an endoscopic marker for the resection of the muscularis propria and potential perforation during colonic endoscopic mucosal resection. Gastrointest Endosc 2011; 73:79.
- Nivatvongs S, Snover DC, Fang DT. Piecemeal snare excision of large sessile colon and rectal polyps: is it adequate? Gastrointest Endosc 1984; 30:18.
- Belderbos TD, Leenders M, Moons LM, Siersema PD. Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis. Endoscopy 2014; 46:388.
- Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 2008; 134:1570.
- PATIENT SELECTION
- Features suggesting invasive cancer
- Polyp size and location
- PATIENT PREPARATION
- Snare polypectomy
- Endoscopic mucosal resection techniques
- - Determine the polyp's margins
- - Submucosal injection
- - Resection
- - Treatment of residual adenoma
- Endoscopic submucosal dissection techniques
- Preventing bleeding
- Specimen collection and histologic evaluation
- Efficacy of endoscopic mucosal resection
- Efficacy of endoscopic submucosal dissection
- Effect of prior polyp manipulation
- Efficacy for treating serrated lesions
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS