Colonic polyps Difficult polyps
Download as PPTX, PDF2 likes715 views
This document discusses methods for removing difficult colonic polyps. It describes various techniques including cold biopsy forceps, hot biopsy forceps, cold snare polypectomy, hot snare polypectomy, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD). It provides details on these techniques and recommends methods based on polyp size, location, and complexity. For example, it recommends cold snare polypectomy for sessile polyps 6-9mm and hot snare polypectomy for sessile polyps 10-19mm. The document also describes a SMSA scoring system for classifying polyp difficulty and outlines factors associated with incomplete resection or recurrence.
Colonic polyps Difficult polyps
- 1. How To Remove Colonic Polyps? By Shaimaa Elkholy, M.D Cairo University
- 2. Agenda • What do we need before polypectomy? • What are the methods used? • What types of snares? • What do guidelines say? • How to follow up?
- 3. What do we need before polypectomy?
- 4. What are the methods used?
- 5. What are the methods used? • Cold Biopsy Forceps (CBF) • Hot Biopsy Forceps (HBF) • Cold Snaring Polypectomy (CSP) • Hot Snaring Polypectomy (HSP) • Endoscopic mucosa resection (EMR) • Endoscopic submucosa dissection (ESD)
- 6. Cold Biopsy Forceps (CBF) video
- 7. Cold Biopsy Forceps (CBF) • 25 % residual tissue • It needs to be less than the biopsy forceps diameter • Resection rate >>> 39% (< 5mm) >>> 86 % (<5mm) >>> 92 – 100 % (<3mm)
- 8. Hot Biopsy Forceps (HBF)
- 9. Hot Biopsy Forceps (HBF) -High rates of incomplete resection -Inadequate tissue sampling -High risks of adverse events (deep thermal injury & delayed bleeding)
- 10. Cold Snaring Polypectomy (CSP) video
- 11. Cold Snaring Polypectomy (CSP) • RCTs (CSP Vs HSP) in polyps less than 8-10 mm >>> Less intra procedure bleeding (5.7 % Vs 23%) >>> Less post procedure bleeding (0 % Vs 14%) >>> post procedure pain (2.5% Vs 20%) >>> complete resection (94% Vs 93%)
- 12. Cold Snaring Polypectomy (CSP) Lower rates of delayed bleeding Lower frequency of post-polypectomy Syndrome Shorter procedure duration
- 13. Piecemeal- CSP - For 10-19mm polyps - Few studies - Very safe (no bleeding, no perforation, no pain) - Histological assessment ?! - Head to head studies are still needed
- 14. Hot Snaring Polypectomy (HSP) video
- 15. What types of snares?
- 17. • For routine sessile polyps a 15 or 20 mm snare (regular stiffness) is easiest for laying the snare down / tissue grasping / size relative to polyp • Flat polyps require stiff/braided snares (and lifting) *A lot of snares have the same handle and color within the same company but behave very differently – read the catalog!!
- 18. What do guidelines say?
- 19. Cold Biopsy Forceps (CBF) -ESGE recommends AGAINST the use of CBF (high rates of incomplete resection) -Polyp 1 –3mm & cold snaring is technically difficult or not possible >> CBF MAY be used (Moderate quality evidence; strong recommendation)
- 20. Hot Biopsy Forceps (HBF) -ESGE recommends AGAINST the use of HBF (High quality evidence; strong recommendation)
- 21. Cold Snaring Polypectomy (CSP) ESGE suggests CSP for sessile polyps 6 –9mm in size because of its superior safety profile, although evidence comparing efficacy with HSP is lacking (Moderate quality evidence; weak recommendation)
- 22. Piecemeal- CSP There may be a role for p-CSP to reduce the risk of deep mural injury, but further studies are needed (Low quality evidence; wea recommendation)
- 23. Hot Snaring Polypectomy (HSP) -ESGE suggests HSP (+ submucosal injection) for sessile polyps 10 – 19mm -Deep thermal injury is a potential risk & thus submucosal injection should be considered (Low quality evidence; strong recommendation)
- 24. Hot Snaring Polypectomy (HSP) -ESGE suggests HSP for pedunculated polyps -Head > 20mm or stalk > 10mm, prior adrenaline injection + mechanical compression (Moderate quality evidence; strong recommendation)
- 25. CRC polyps < 5mm CSP 6-9 mm CSP > 10mm Advanced imaging Detect submucosal invasion Sessile or flat Pedunculated Head < 20mm & stalk<10mm HSP Head>20mm or stalk >10mm Dil adrenaline + mech compression then HSP
- 26. > 10mm 10-19mm HSP, SC injection better > 20 mm EMR, p-EMR If > 40mm refer to expert center Non-invasive Suspected invasion Superficial Tattoo & refer for ESD Deep Tattoo & refer for surgery
- 27. Diminutive polyps (<5mm) at recto-sigmoid • photo
- 28. Diminutive polyps (<5mm) at recto-sigmoid • If highly confident to be hyperplastic (Expert) >>>> leave or >> resect & discard
- 29. How to follow up?
- 30. Low risk group 1-2 tubular adenomas + < 10mm + low grade of dysplasia >>> 10 years from index (either in a screening program or not) High risk group > 3 adenomas Or Villous Or > 10mm Or high grade of dysplasia >>> 3 years after index
- 31. If > 10 adenomas >>> Genetic counselling
- 32. High risk group • In first surveillance colonoscopy - If NO high-risk adenomas >> 5-year interval - If high-risk adenomas >> 3-year interval
- 33. For serrated polyps • If < 10mm & no dysplasia >>> LOW risk • If > 10 mm Or dysplasia >>> High risk
- 35. Difficult Colonic Polyps By Shaimaa Elkholy, M.D Cairo University
- 36. Objectives •What is a Difficult polyp? •How can we manage?
- 37. What is Difficult Polyp?
- 38. Difficult Polyp • Size (large, long stalk, thick stalk …) • Site (flexures, behind a fold, cecum, ileocecal valve ….) • Type (flat, …) • Accessibility • Narrow lumen • Incomplete resection • Recurrence
- 39. No consensus or strict criteria for definition
- 41. SMSA Scoringsystem Factors Benchmarks Points Size < 1 cm 1 1 - 1.9 cm 3 2 – 2.9 cm 5 3 – 3.9 cm 7 > 4 cm 9 Morphology Pedunculated 1 Sessile 2 Flat 3 Site Left 1 Right 2 Access Easy 1 Difficult Level 1 (4-5) Level 2 (6-9) Level 3 (10-12) Level 4 (>12)
- 42. • Level 1 (4 – 5) >> all endoscopist should be able to do • Level 2 (6 - 9) >> Advanced • Level 3 (10-12) >> Expert • Level 4 (>12) >> referral to tertiary center / surgery
- 44. 2018, 2675 patients, 9 yr
- 45. P-value < 0.001
- 46. SMSA level Total no=2675 SMSA 2 175 (6.5 %) SMSA 3 1110 (41.5%) SMSA 4 1390 (52 %) P-value Deep injury, n (%) 4 (2.3 %) 16 (1.4%) 31 (2.2%) 0.34 IP bleeding 20 (11.4%) 144 (13 %) 368 (26.5%) <0.001 Delayed bleeding 3 (1.7%) 48 (4.3%) 97 (7 %) <0.001 Delayed perforation 0 (0) 3 (0.3 %) 8 (0.6 %) 0.40 Surgery 2 weeks 21 (12 %) 71 (6.4 %) 157 (11.3 %) <0.001
- 47. P-value < 0.001
- 48. P-value < 0.001
- 49. SMSA • Simple, Readily Applicable Clinical Score • Risk of failure, Adverse Events & Recurrence
- 50. • Not to scare the doctors • Just to expect • Be fully equipped • The patient knowledge • Better consenting
- 51. Other Reviews ……
- 52. Other Reviews …… • Recurrent • Incompletely resected • Crossing two haustral folds • Peri diverticular • Touching dentate line • Non – ideal situation • In experienced endoscopist
- 53. What do we need before polypectomy?
- 55. Others
- 56. First • Locate the polyp •Analyze polyp’s shape •Determine the polyp’s size •Analyze the polyps surface •Determine the number of polyps •Position the polyp before attempting resection •Estimate polyp respectability using endoscopic methods •Use submucosal cushion •Choose accordingly
- 57. Methods for removal of difficult polyps • Endoloop • Clipping • EMR • p-EMR • u-EMR • ESD (conventional, pocket) • Hybrid resection
- 62. p-EMR
- 65. • Complete resection rate was 96.36% • en bloc resection of 57.07% • Recurrence rate was 8.82% (range 4-15 months) • Postprocedural bleeding rate was 2.85% • Bleeding was always mild • Overall adverse event rate was 3.31% • No cases of perforation were reported Very Safe
- 66. ESD (Endoscopic Submucosal Dissection)
- 71. Features associated with incomplete resection or recurrence include; • Lesion size > 40mm • ileocecal valve location • Prior failed attempts of resection • SMSA level 4 (Moderate quality evidence; strong recommendation)
- 72. • The majority of colonic and rectal lesions can be effectively removed in a curative way by standard polypectomy and/or by EMR (Moderate quality evidence; strong recommendation)