Diminutive Polyps: The Optimal Treatment. Siwan Thomas-Gibson St Marks Hospital London UK

Transcription

1 Diminutive Polyps: The Optimal Treatment Siwan Thomas-Gibson St Marks Hospital London UK

2 Outline How common What s the point? Polypectomy methods Structured technique

3 What is a Diminutive Polyp? A polyp </= 5mm Mean per colonoscopist Range Caecal intubation rate 95.2% % Adenoma detection rate Mean withdrawal time 9.4 minutes 46.5% % minutes Polyp retrieval rate 92.7% % Mean Adenomas per Patient BCSP data England curtesy Matt Rutter

4 HGD What s The Risk? Malignancy 6-9mm 0.4% 0% * % 0.9% % >30mm 38.1% Pickhardt; Clinical Gastroenterology and Hepatology; mm? Under-estimate? 8.7% unfavourable histology in diminutive polyps Repici et al Endoscopy 2012

5 Polypectomy Technique for Diminutive Lesions

6 Diminutive Polyps Morphology Polyp position Polyp site On insertion or withdrawal Hot Biopsy?? Cold forceps Cold snare Hot snare Lift or not Tip: Position the polyp

7 Hot Biopsy Consider using cold forceps Technique all important: BIOPSY not polypectomy Polyps <4mm Not proximal to splenic flexure Many say never 22% residual polyp left (Ellis GIE 1997) Risk of bleed and perforation If 2-3mm can remove with cold forceps= polypectomy Tip: Think cold forceps

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10 Easy Cold Forceps >3mm consider jumbo forceps Safe: negligible risk of bleeding/perforation Retrieval and histological confirmation BUT Minor bleeding may make assessment of completeness difficult? 61% incomplete removal, 30% recurrence Fyock WJG 2010, Singh GIE 2004 Rex Endoscopy 2010, Tolliver GCNA 2008 Repici Endoscopy 2012, Graser Gut 2009, Hewett CGH 2011

11 Cold Snare: no lift

12 Tip: Use mini-snare

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14 Definitive resection?

15 Cold Snare Indicated (unfavourable histology up to 8.7%) Easy, usually Safe (2.2% immediate, controlled, bleeding) Doing nothing leaves risk 100% time! BUT Retrieval can be difficult (84-95% retrieval rates) Can be incomplete Repici Endoscopy 2012 Monkemuller CGH 2009 Deenadayalu GIE 2005

16 Hot Snare, no lift Tip: Using heat- tent the mucosa

17 Lift or no lift? Morphology Size polyp Site polyp Sessile polyps Most sessile lesions are semi-pedunculated, pseudo-stalk Snare in one piece Right colon, think lift True flat/depressed lesions: lift Tip: If sessile think lift?

18 Cold Snare: Lift

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20 Hot Snare Lift Tip: Always close the snare yourself

21 Small Stalked Polyps Position polyp favourably Check and mark snare Check diathermy settings Coag +/- Cut Position foot pedal Open Snare within scope channel, beyond polyp

22 Push snare sheath against stalk Close snare from behind Thinnest part of stalk (mid-upper 1/3) Close snare to the mark (begin coaptation) Endoscopist takes snare Apply current, watch for visible whitening Endoscopist squeezes and transects Watch where polyp falls (or liquid pooling)

23 Top Tips: Small Polyps Tip: Position the polyp Tip: Think cold forceps Tip: Use mini-snare Tip: If sessile think lift? Tip: Always check The Mark Tip: Using heat- tent the mucosa Tip: Close the snare yourself Tip: Retrieve on snare / look for fluid pool

24 DOPyS Assessment/ pre-polypectomy Stalked polyps Sessile polyps/emr Have a routine Stick to it Trainee certification Bowel cancer screener accreditation Post-polypectomy Overall competency

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