Clinical Endoscopy

The Korean Society of Gastrointestinal Endoscopy (대한소화기내시경학회)
권호 표지
DOI QR코드

DOI QR Code

Endoscopic management of giant colonic polyps: a retrospective Italian study

  • Paolo Quitadamo (Pediatric Gastroenterology and Hepatology Unit, Santobono-Pausilipon Children's Hospital) ;
  • Sara Isoldi (Pediatric Gastroenterology and Hepatology Unit, Santobono-Pausilipon Children's Hospital) ;
  • Germana De Nucci (Gastroenterology and Endoscopy Unit, Garbagnate Milanese Hospital) ;
  • Giulia Muzi (NESMOS Department, Pediatric Unit, Sapienza University of Rome) ;
  • Flora Caruso (Hepatogastroenterology Division, Department of Precision Medicine, University of Campania Luigi Vanvitelli)
  • Received : 2023.09.12
  • Accepted : 2024.01.14
  • Published : 2024.07.30
Download PDF
⟨ Previous Next ⟩

Abstract

Background/Aims: Polyps greater than 30 mm are classified as "giants". Their endoscopic removal represents a technical challenge. The choice of the endoscopic removal technique is important because it provides a resection sample for precise histopathological staging. This is pivotal for diagnostic, prognostic, and management purposes. Methods: From a retrospective analysis, we obtained a sample of 38 giant polyps. Eighteen polypectomies were performed using the epinephrine volume reduction (EVR) method, nine polypectomies utilized endo-looping or clipping methods, and 11 patients underwent surgery. Results: We obtained en bloc resection with the EVR method in all cases; histology confirmed the correct indication for endoscopic resection in all cases. Moreover, no early or delayed complications were observed, and no patient required hospitalization. Using endo-looping or clipping methods, we observed advanced histology in 1/9 (11.1%) cases, while another patient (1/9, 11.1%) had delayed bleeding. Among patients who underwent surgery, 5/11 (45.5%) were deemed overtreated and three had post-surgical complications. Conclusions: We propose EVR as an alternative technique for giant polyp resection due to its safety, effectiveness, cost-efficiency, and the advantage of avoiding the need to postpone polypectomy to a later time. Further prospective studies might help improve this experience and enhance the technique.

Keywords

References

  1. Coverlizza S, Risio M, Ferrari A, et al. Colorectal adenomas containing invasive carcinoma. Pathologic assessment of lymph node metastatic potential. Cancer 1989;64:1937-1947. https://doi.org/10.1002/1097-0142(19891101)64:9<1937::AID-CNCR2820640929>3.0.CO;2-X
  2. Cannon-Albright LA, Bishop DT, Samowitz W, et al. Colonic polyps in an unselected population: prevalence, characteristics, and associations. Am J Gastroenterol 1994;89:827-831.
  3. Fong TV, Chuah SK, Chiou SS, et al. Correlation of the morphology and size of colonic polyps with their histology. Chang Gung Med J 2003;26:339-343.
  4. Choi YS, Lee JB, Lee EJ, et al. Can endoscopic submucosal dissection technique be an alternative treatment option for a difficult giant (≥ 30 mm) pedunculated colorectal polyp? Dis Colon Rectum 2013;56:660-666. https://doi.org/10.1097/DCR.0b013e318276d2b9
  5. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003;58(6 Suppl):S3-S43. https://doi.org/10.1016/S0016-5107(03)02159-X
  6. Kudo S, Rubio CA, Teixeira CR, et al. Pit pattern in colorectal neoplasia: endoscopic magnifying view. Endoscopy 2001;33:367-373. https://doi.org/10.1055/s-2004-826104
  7. dos Santos CE, Lima JC, Lopes CV, et al. Computerized virtual chromoendoscopy versus indigo carmine chromoendoscopy combined with magnification for diagnosis of small colorectal lesions: a randomized and prospective study. Eur J Gastroenterol Hepatol 2010;22:1364-1371. https://doi.org/10.1097/MEG.0b013e32833a5d63
  8. Kudo S, Tamura S, Nakajima T, et al. Diagnosis of colorectal tumorous lesions by magnifying endoscopy. Gastrointest Endosc 1996;44:8-14. https://doi.org/10.1016/S0016-5107(96)70222-5
  9. Fujii T, Hasegawa RT, Saitoh Y, et al. Chromoscopy during colonoscopy. Endoscopy 2001;33:1036-1041.
  10. Sano Y, Emura F, Ikemats H. Narrow band imaging. In: Waye JD, Rex DK, Williams CB, editors. Colonoscopy: principles and practice. 2nd ed. Wiley-Blackwell; 2009. p. 514-526.
  11. Kanao H, Tanaka S, Oka S, et al. Narrow-band imaging magnification predicts the histology and invasion depth of colorectal tumors. Gastrointest Endosc 2009;69(3 Pt 2):631-636. https://doi.org/10.1016/j.gie.2008.08.028
  12. Wada Y, Kudo SE, Kashida H, et al. Diagnosis of colorectal lesions with the magnifying narrow-band imaging system. Gastrointest Endosc 2009;70:522-531. https://doi.org/10.1016/j.gie.2009.01.040
  13. Naini BV, Odze RD. Advanced precancerous lesions (APL) in the colonic mucosa. Best Pract Res Clin Gastroenterol 2013;27:235-256. https://doi.org/10.1016/j.bpg.2013.03.012
  14. Kudo Se, Lambert R, Allen JI, et al. Nonpolypoid neoplastic lesions of the colorectal mucosa. Gastrointest Endosc 2008;68(4 Suppl):S3-S47. https://doi.org/10.1016/j.gie.2008.07.052
  15. Bianco MA, Cipolletta L, Rotondano G, et al. Prevalence of nonpolypoid colorectal neoplasia: an Italian multicenter observational study. Endoscopy 2010;42:279-285. https://doi.org/10.1055/s-0029-1244020
  16. O'Brien MJ, Winawer SJ, Zauber AG, et al. The National Polyp Study. Patient and polyp characteristics associated with high-grade dysplasia in colorectal adenomas. Gastroenterology 1990;98:371-379. https://doi.org/10.1016/0016-5085(90)90827-N
  17. Stulc JP, Petrelli NJ, Herrera L, et al. Colorectal villous and tubulovillous adenomas equal to or greater than four centimeters. Ann Surg 1988;207:65-71. https://doi.org/10.1097/00000658-198801000-00013
  18. Fung CH, Goldman H. The incidence and significance of villous change in adenomatous polyps. Am J Clin Pathol 1970;53:21-25. https://doi.org/10.1093/ajcp/53.1.21
  19. Boyce HW Jr. "Malignant" colon polyps: pathologist's obligation and clinician's dilemma. Gastrointest Endosc 1980;26:56-57. https://doi.org/10.1016/S0016-5107(80)73273-X
  20. Fenoglio CM, Haggitt RC, Hamilton SR, et al. Colonic dysplasia. Pathol Annu 1981;16 Pt 1:181-213.
  21. Pigo F, Bertani H, Grande G, et al. Post-polypectomy bleeding after colonoscopy on uninterrupted aspirin/non steroideal antiflammatory drugs: systematic review and meta-analysis. Dig Liver Dis 2018;50:20-26. https://doi.org/10.1016/j.dld.2017.10.005
  22. Nivatvongs S. Complications in colonoscopic polypectomy: an experience with 1,555 polypectomies. Dis Colon Rectum 1986;29:825-830. https://doi.org/10.1007/BF02555356
  23. Smith LE. Fiberoptic colonoscopy: complications of colonoscopy and polypectomy. Dis Colon Rectum 1976;19:407-412. https://doi.org/10.1007/BF02590825
  24. Webb WA, McDaniel L, Jones L. Experience with 1000 colonoscopic polypectomies. Ann Surg 1985;201:626-632. https://doi.org/10.1097/00000658-198505000-00012
  25. Gibbs DH, Opelka FG, Beck DE, et al. Postpolypectomy colonic hemorrhage. Dis Colon Rectum 1996;39:806-810. https://doi.org/10.1007/BF02054448
  26. von Delius S, Thies P, Umgelter A, et al. Hemodynamics after endoscopic submucosal injection of epinephrine in patients with nonvariceal upper gastrointestinal bleeding: a matter of concern. Endoscopy 2006;38:1284-1288. https://doi.org/10.1055/s-2006-944959
  27. 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.
  28. 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;36:860-863. https://doi.org/10.1055/s-2004-825801
  29. Hachisu T. A new detachable snare for hemostasis in the removal of large polyps or other elevated lesions. Surg Endosc 1991;5:70-74. https://doi.org/10.1007/BF00316840
  30. Iishi H, Tatsuta M, Narahara H, et al. Endoscopic resection of large pedunculated colorectal polyps using a detachable snare. Gastrointest Endosc 1996;44:594-597. https://doi.org/10.1016/S0016-5107(96)70015-9
  31. Matsushita M, Hajiro K, Takakuwa H, et al. Ineffective use of a detachable snare for colonoscopic polypectomy of large polyps. Gastrointest Endosc 1998;47:496-499. https://doi.org/10.1016/S0016-5107(98)70251-2
  32. Dobrowolski S, Dobosz M, Babicki A, et al. Prophylactic submucosal saline-adrenaline injection in colonoscopic polypectomy: prospective randomized study. Surg Endosc 2004;18:990-993. https://doi.org/10.1007/s00464-003-9214-6
  33. Kouklakis G, Mpoumponaris A, Gatopoulou A, et al. Endoscopic resection of large pedunculated colonic polyps and risk of postpolypectomy bleeding with adrenaline injection versus endoloop and hemoclip: a prospective, randomized study. Surg Endosc 2009;23:2732-2737. https://doi.org/10.1007/s00464-009-0478-3
  34. Hogan RB, Hogan RB 3rd. Epinephrine volume reduction of giant colon polyps facilitates endoscopic assessment and removal. Gastrointest Endosc 2007;66:1018-1022. https://doi.org/10.1016/j.gie.2007.03.1078
  35. Inoue Y, Tezuka T, Shinohara T, et al. Endoscopic mucosal resection of colorectal tumors. Dig Endosc 2004;16:91-94. https://doi.org/10.1111/j.1443-1661.2004.00315.x
  36. Park Y, Jeon TJ, Park JY, et al. Comparison of clipping with and without epinephrine injection for the prevention of post-polypectomy bleeding in pedunculated colon polyps. J Gastroenterol Hepatol 2015;30:1499-1506. https://doi.org/10.1111/jgh.12994
  37. Lee SH, Lee KS, Park YS, et al. Submucosal saline-epinephrine injection in colon polypectomy: appropriate indication. Hepatogastroenterology 2008;55:1589-1593.
  38. Shioji K, Suzuki Y, Kobayashi M, et al. Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy. Gastrointest Endosc 2003;57:691-694. https://doi.org/10.1067/mge.2003.193
  39. Ferlitsch M, Moss A, Hassan C, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017;49:270-297. https://doi.org/10.1055/s-0043-102569
  40. Waye JD, Lewis BS, Yessayan S. Colonoscopy: a prospective report of complications. J Clin Gastroenterol 1992;15:347-351. https://doi.org/10.1097/00004836-199212000-00018
  41. Hsieh YH, Lin HJ, Tseng GY, et al. Is submucosal epinephrine injection necessary before polypectomy?: a prospective, comparative study. Hepatogastroenterology 2001;48:1379-1382.
  42. Katsinelos P, Kountouras J, Paroutoglou G, et al. Endoloop-assisted polypectomy for large pedunculated colorectal polyps. Surg Endosc 2006;20:1257-1261. https://doi.org/10.1007/s00464-005-0713-5