Theoretical Basis of Polypectomy: A Webinar
A 2.5 hour tour of the important concepts in polypectomy theory in 2022. These concepts are explored more deeply in the other courses that we offer throughout the site.

In brief

The video highlights the importance of evaluating the demarcated area and matching the polyp to the endoscopist's expertise. Technique selection should consider polyp characteristics and the endoscopist's skill, with an accurate selection of the snares. Evaluating scars, regular surveillance, and competency in handling referrals are essential. Understanding diathermy settings is vital, especially for margin ablation. Continuous learning, particularly in scar assessment and current practices, significantly enhances patient outcomes.

Detailed Summary

Here is a list of key learning points from the video:
  • Evaluation of Demarcated Area: The demarcated area can provide important clues about the presence of submucosal invasion. The irregular or disrupted demarcation may indicate deeper tissue involvement and a higher likelihood of malignancy.
  • Matching the Polyp to the Endoscopist: It is crucial to consider the expertise and skill set of the endoscopist when determining the appropriate management approach for a polyp. Not all polyps are equal, and their characteristics may vary in terms of size, location, morphology, and complexity.
  • Choosing the Appropriate Technique: When approaching the management of a polyp, it is important to carefully consider the characteristics of the polyp and select the most appropriate technique for its removal. Factors such as size, location, morphology, histology, and the endoscopist's expertise should be taken into account.
  • Snare Selection: The use of braided snares is preferred over monofilament snares for polypectomy due to better application of diathermy and the need to clean carbonized tissue off the snare tip.
  • Assessing Scars: When evaluating scar tissue for recurrence, look for a pale area without large vessels in the center, with a pit pattern that is more open and larger than the surrounding mucosa.
  • Surveillance: Regular surveillance is essential for detecting recurrence within scars. The negative predictive value of endoscopic assessment is high when performed by experienced practitioners, but biopsies can still be performed for confirmation.
  • Competency and Referral: Expert centers should handle the first follow-up surveillance at 6-12 months for higher-risk cases while referring lower-risk cases back to the primary endoscopist. Competence in assessing and treating scars is crucial to avoid unnecessary procedures.
  • Diathermy Settings: Understanding the settings on the diathermy generator is important. The yellow and blue pedals indicate mixed coagulation and cutting currents, with soft coag being the purest coagulation current for margin ablation.
  • Continuous Learning: It is crucial to continually learn and improve endoscopy techniques. Developing expertise in scar assessment and staying updated with best practices can improve patient outcomes.
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Cold Snare Polypectomy Theory
Safety
Decision making in Polypectomy
4 Ps - Plan4 Ps - Plane4 Ps - Position4 Ps - ProximityEn bloc versus piecemeal resectionEndoscopic versus Surgical ManagementHot versus cold snare polypectomyWhether to biopsy a suspicious polyp
Deconstructed Cold Snare Polypectomy
Snare selection
Deconstructed Polypectomy Technique
Injection techniquePost polypectomy defect assessmentSafety checks prior to application of diathermySnare placementThermal ablation of the post-polypectomy margin
Defect inspection deconstructed
Deep mural injuryMargin assessment for residualResidual adenomaSubmucosal blood vessels
Difficult Polypectomy Locations
Appendiceal orifice
Endoscopic Markers of Submucosal Invasion [colon]
[high risk] Demarcated area of disordered pit/vascular pattern[high risk] Depression with disordered pit/vascular pattern[high risk] Left colon location, large nodule(s)[high risk] presence of nodules
Equipment
Diathermy
Granularity
GranularNon-granular
Imaging Classifications for Colorectal Polyps
Demarcated areaDysplasia within a sessile serrated polypGranularityKudo ClassificationNICE classificationParis ClassificationWASP classification
Imaging modalities
Virtual chromoendoscopy
JNET Classification
JNET 1JNET 2AJNET 2BJNET 3
Markers of Polypectomy Difficulty
Difficult Colon IntubationGlobal Polypectomy Assessment Tool (GPAT)SMSA + ScoreSMSA Score
Paris Classification
Paris 0-IIaParis 0-IIa+cParis 0-IIa+Is
Polyp Size
Small (less than 10mm)
Polypectomy
Assessment
Polypectomy Scoring Systems
Risk of Submucosal Invasion
Polypectomy technique
Cold Snare Polypectomy
Post Polypectomy Surveillance
Recurrent polypScar biopsy techniqueScar detectionStandardised scar assessment techniqueTreatment of recurrent polyp
Prevention of adverse events at polypectomy
Thermal ablation of the post-resection defect margin
SMSA Score
SMSA Level 3SMSA Level 4
Submucosal Injection Technique
Dynamic injection
Training
Proactive ApproachReasons for failure
Video Type
Lecture with AudioWebinar
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References

1 - IJspeert JE, Bastiaansen BA, . Development and validation of the WASP classification system for optical diagnosis of adenomas, hyperplastic polyps and sessile serrated adenomas/polyps. Gut, 2016 vol. 65(6) pp. 963-70. Polypectomy / Assessment

2 - Hewett DG, Kaltenbach T, Rex DK. Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging. Gastroenterology, 2012 vol. 143(3) pp. 599-607.e1. 10.1053/j.gastro.2012.05.006.Polypectomy / Assessment

3 - Desomer L, Tate DJ, Bourke MJ. A systematic description of the post-EMR defect to identify risk factors for clinically significant post-EMR bleeding in the colon. Gastrointestinal endoscopy, 2019 vol. 89(3) pp. 614-624. 10.1016/j.gie.2018.11.023.Deconstructed Polypectomy Technique / Post polypectomy defect assessment

4 - Klein A, Tate DJ, Bourke MJ. Thermal Ablation of Mucosal Defect Margins Reduces Adenoma Recurrence After Colonic Endoscopic Mucosal Resection. Gastroenterology, 2019 vol. 156(3) pp. 604-613.e3. 10.1053/j.gastro.2018.10.003.Deconstructed Polypectomy Technique / Thermal ablation of the post-polypectomy margin

5 - Tate DJ, Desomer L, Bourke MJ. EMR of laterally spreading lesions around or involving the appendiceal orifice: technique, risk factors for failure, and outcomes of a tertiary referral cohort (with video). Gastrointestinal endoscopy, 2018 vol. 87(5) pp. 1279-1288.e2. 10.1016/j.gie.2017.12.018.Difficult Polypectomy Locations / Appendiceal orifice

6 - Hewett DG, Kaltenbach T, Rex DK. Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging. Gastroenterology, 2012 vol. 143(3) pp. 599-607.e1. 10.1053/j.gastro.2012.05.006.Imaging Classifications for Colorectal Polyps / NICE classification

7 - Hayashi N, Tanaka S, Soetikno RM. Endoscopic prediction of deep submucosal invasive carcinoma: validation of the narrow-band imaging international colorectal endoscopic (NICE) classification. Gastrointestinal endoscopy, 2013 vol. 78(4) pp. 625-32. 10.1016/j.gie.2013.04.185.Imaging Classifications for Colorectal Polyps / NICE classification

8 - Kudo SE, Kashida H, Kashida H. Flat and depressed lesions of the colorectum. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Ga Imaging Classifications for Colorectal Polyps / Kudo Classification

9 - Bisschops R, East JE, Dekker E. Advanced imaging for detection and differentiation of colorectal neoplasia: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2019. Endoscopy, 2019 vol. 51(12) pp. 1155-1179. Imaging Classifications for Colorectal Polyps / Demarcated area

10 - Matsuda T, Fujii T, Fujimori T. Efficacy of the invasive/non-invasive pattern by magnifying chromoendoscopy to estimate the depth of invasion of early colorectal neoplasms. The American journal of gastroenterology, 2008 vol. 103(11) pp. 2700-6. Imaging Classifications for Colorectal Polyps / Demarcated area

11 - Multiple, , Multiple. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointestinal endoscopy, 2003 vol. 58(6 Suppl) pp. S3-43. Paris Classification / Paris 0-IIa+c

12 - Kandel P, Brand EC, . Endoscopic scar assessment after colorectal endoscopic mucosal resection scars: when is biopsy necessary (EMR Scar Assessment Project for Endoscope (ESCAPE) trial). Gut, 2019 vol. 68(9) pp. 1633-1641. Post Polypectomy Surveillance / Standardised scar assessment technique

13 - Desomer L, Tutticci N, Bourke MJ. A standardized imaging protocol is accurate in detecting recurrence after EMR. Gastrointestinal endoscopy, 2017 vol. 85(3) pp. 518-526. 10.1016/j.gie.2016.06.031.Post Polypectomy Surveillance / Standardised scar assessment technique

14 - Ferlitsch M, Moss A, Bourke MJ. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy, 2017 vol. 49(3) pp. 270-297. Decision making in Polypectomy / En bloc versus piecemeal resection

15 - Tate DJ, Sidhu M, Bourke MJ. Impact of en bloc resection on long-term outcomes after endoscopic mucosal resection: a matched cohort study. Gastrointestinal endoscopy, 2020 vol. 91(5) pp. 1155-1163.e1. 10.1016/j.gie.2019.12.025.Decision making in Polypectomy / En bloc versus piecemeal resection

16 - Burgess NG, Hourigan LF, Bourke MJ. Risk Stratification for Covert Invasive Cancer Among Patients Referred for Colonic Endoscopic Mucosal Resection: A Large Multicenter Cohort. Gastroenterology, 2017 vol. 153(3) pp. 732-742.e1. 10.1053/j.gastro.2017.05.047.Endoscopic Markers of Submucosal Invasion [colon] / [high risk] Left colon location, large nodule(s)

17 - Soetikno R, Kaltenbach T, Kaltenbach T. Dynamic submucosal injection technique. Gastrointestinal endoscopy clinics of North America, 2010 vol. 20(3) pp. 497-502. Submucosal Injection Technique / Dynamic injection

18 - Tate DJ, Jayanna M, Bourke MJ. A standardized imaging protocol for the endoscopic prediction of dysplasia within sessile serrated polyps (with video). Gastrointestinal endoscopy, 2018 vol. 87(1) pp. 222-231.e2. 10.1016/j.gie.2017.06.031.Imaging Classifications for Colorectal Polyps / Dysplasia within a sessile serrated polyp

19 - Bettington M, Walker N, Whitehall V. Clinicopathological and molecular features of sessile serrated adenomas with dysplasia or carcinoma. Gut, 2017 vol. 66(1) pp. 97-106. Imaging Classifications for Colorectal Polyps / Dysplasia within a sessile serrated polyp

20 - Ahlenstiel G, Hourigan LF, . Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointestinal endoscopy, 2014 vol. 80(4) pp. 668-676. 10.1016/j.gie.2014.04.015.Decision making in Polypectomy / Endoscopic versus Surgical Management

21 - Burgess NG, Bassan MS, Bourke MJ. Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors. Gut, 2017 vol. 66(10) pp. 1779-1789. Defect inspection deconstructed / Deep mural injury

22 - Gupta S, Miskovic D, Thomas-Gibson S. A novel method for determining the difficulty of colonoscopic polypectomy. Frontline gastroenterology, 2013 vol. 4(4) pp. 244-248. Markers of Polypectomy Difficulty / SMSA Score

23 - Sidhu M, Tate DJ, Bourke MJ. The size, morphology, site, and access score predicts critical outcomes of endoscopic mucosal resection in the colon. Endoscopy, 2018 vol. 50(7) pp. 684-692. Markers of Polypectomy Difficulty / SMSA Score