THE KNACKS OF CONVENTIONAL POLYPECTOMY, COLD POLYPECTOMY AND ENDOSCOPIC MUCOSAL RESECTION IN THE COLORECTUM

Abstract

A pedunculated polyp is an indication for conventional polypectomy, while a polyp that is sessile or flat and is large or suspected of being cancer is an indication for endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). Cold polypectomy is indicated for a small (≤10mm) sessile or flat polyp that is not suspected of being cancer.

In polypectomy for a pedunculated polyp, the snare should be placed close to the polyp head. In cases where the stalk of the polyp is very thick, it is recommended that an endoloop be applied to the base of the stalk before cutting with a snare for the purpose of preventing hemorrhage. In cold polypectomy, a certain distance between the snare wire and the polyp margin should always be maintained during closure of the snare in order to secure a tumor-free margin. The success of EMR largely depends on how the solution is injected. In the case of a lesion lying over a flexure or a fold, injection should be started from the proximal side. If the lesion is large, injection can be done through the center of the lesion as long as it is not suspected of being invasive cancer. In order to obtain a good lift of the lesion, the tip of the needle should be slightly lifted and slowly withdrawn during the injection. The snare should be pushed against the colonic wall during an attempt to capture the lesion, but not too much in order not to involve the proper muscle layer. If the patient complains of pain or if the assistant feels much resistance during cutting with the electric current, the procedure should be suspended as the muscle layer might be involved.