Abstract
Adenomatous colon polyps are precursors to colon cancer, and colonoscopic polypectomy reduces both the incidence and mortality of colorectal cancer. Adequate bowel preparation, endoscopic irrigation, and meticulous suctioning permit thorough and complete mucosal evaluation to detect and treat all colonic neoplasia. This chapter details contemporary evaluation and management of adenomatous colon polyps discovered at colonoscopy.
Access provided by Autonomous University of Puebla. Download chapter PDF
Similar content being viewed by others
Keywords
Algorithmic Approach
-
A.
Adenomatous colon polyp s are precursors to colon cancer , and colonoscopic polypectomy reduces both the incidence and mortality of colorectal cancer [1]. Adequate bowel preparation, endoscopic irrigation, and meticulous suctioning permit thorough and complete mucosal evaluation to detect and treat all colonic neoplasia.
-
B.
Following polyp identification, thorough irrigation and suctioning are performed to adequately assess polyp-specific features to guide management and enable treatment. Determination of polyp size, morphology, and location is essential, and use of Paris classification to characterize polyp morphology is encouraged [2]. Malignant tumors are differentiated from benign adenomas by size, firmness, central depression, ulceration, and fixation to the deeper bowel wall [3, 4]. Inability to expand peri-polyp submucosa during saline lift (i.e., “non-lifting sign of Uno”) is associated with invasive cancer or scarring from prior polypectomy interventions. Narrow-band imaging, colonoscopic microscopy, and chromoendoscopy may yield additional information about the polyp surface features. Nongranular surface features and irregular nonstructured pits (Kudo pit pattern type V) are both features that should raise suspicion of submucosal invasion and invasive adenocarcinoma [5].
-
C.
Many suggest routinely tattooing all polyps larger than 1–2 cm to facilitate endoscopic surveillance or future surgical resection should the lesion prove to be malignant.
-
D.
Nearly all benign polyps are amenable to endoscopic excision. Cold snare polypectomy is the workhorse for most sessile polyps smaller than 1 cm. Cold forceps can be used to excise the smallest (1–2 mm) polyps; however, this technique is associated with high rates of residual adenomatous tissue [6]. Hot biopsy forceps polypectomy techniques have fallen out of favor due to high rates of delayed bleeding and perforation. Hot snare polypectomy is typically used for pedunculated and larger sessile (>1 cm) polyps. Saline-lift endoscopic mucosal resection (EMR) is a useful technique in which the submucosal layer is first injected with saline to “lift” the polyp, facilitating en bloc or piecemeal resection with a hot snare. EMR is helpful for large polyps, those spanning many folds, and for large right-sided polyps where the bowel wall may be more susceptible to thermal injury. Large postpolypectomy defects may benefit from prophylactic clip closure to decrease the risk of postpolypectomy hemorrhage.
-
E.
Malignant appearing lesions should be biopsied and tattooed, and not removed, since malignancy merits oncologic surgical resection. Indeterminately malignant lesions with benign biopsy pathology may be referred to expert endoscopists for consideration of advanced polypectomy . The endoscopist must be aware of his or her limitations prior to attempting polypectomy because an incomplete polypectomy may cause submucosal scarring and prohibit later EMR attempts by an expert. Special situations may mandate surgical resection regardless of polyp histology. For example, polyps growing into the appendiceal orifice or ileocecal valve are frequently not amenable to endoscopic resection due to the difficulty of obtaining a negative margin, as well as risk of perforation or appendicitis. In these special cases, patients should be referred for advanced expert colonoscopic polypectomy or consideration of surgical resection.
-
F.
If polyp pathology demonstrates no evidence of cancer, surveillance colonoscopy should continue based on the number, size, histology, completeness of polypectomy , bowel preparation quality, and patient and family history. Periodically updated guidelines dictate the frequency of postpolypectomy surveillance for commonly resected polyps in average-risk individuals [7].
-
G.
“Carcinoma in situ” or “intramucosal carcinoma” are confusing terms that describe lack of cancerous invasion of the muscularis mucosa. These lesions are premalignant (i.e., Tis or T0), and colonoscopic resection alone may be adequate. Histology, margins, and depth of malignant invasion determine the adequacy of colonoscopic polypectomy for malignant pedunculated polyps. Haggitt’s classification dictates that polypectomy alone is sufficient for a favorable- histology tumor confined to the polyp stalk with a 2 mm margin from the cut polyp edge [8]. The analogous Kikuchi classification for sessile polyps has shown polypectomy to be sufficient for favorable-histology tumor penetration limited to the upper third (<1 mm) of submucosa [9]. Sessile and pedunculated polyps with deeper submucosal cancerous penetration (>1 mm) should be considered for oncologic surgical resection given the high frequency of lymph node metastases. Regardless of polyp morphology, high-risk pathologic features such as poor differentiation, lymphovascular invasion, and extensive budding increase the risk of lymphatic metastasis and typically mandate oncologic surgical resection [10].
-
H.
Occasionally, polyp margins, histology, and the endoscopist’s assessment of polypectomy completeness may be unclear. In these situations, multidisciplinary review with the endoscopist, surgeon, and pathologist can guide decision-making. In this meeting, the risks of local cancer recurrence and lymph node metastasis should be balanced against the risk of surgical resection, using the patient’s wishes and operative risk to determine the course of subsequent care.
References
Zauber AG, Winawer SJ, O'Brien MJ, Lansdorp-Vogelaar I, van Ballegooijen M, Hankey BF, Shi W, Bond JH, Schapiro M, Panish JF, Stewart ET. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012;366(8):687–96.
Inoue H, Kashida H, Kudo S, Sasako M, Shimoda T, Watanabe H, Yoshida S, Guelrud M, Lightdale CJ, Wang K, Riddell RH. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc. 2003;58(6 Suppl):S3–43.
Galandiuk S, Fazio VW, Jagelman DG, Lavery IC, Weakley FA, Petras RE, Badhwar K, McGonagle B, Eastin K, Sutton T. Villous and tubulovillous adenomas of the colon and rectum: a retrospective review, 1964–1985. Am J Surg. 1987;153(1):41–7.
Doniec JM, Löhnert MS, Schniewind B, Bokelmann F, Kremer B, Grimm H. Endoscopic removal of large colorectal polyps. Dis Colon Rectum. 2003;46(3):340–8.
Moss A, Bourke MJ, Williams SJ, Hourigan LF, Brown G, Tam W, Singh R, Zanati S, Chen RY, Byth K. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology. 2011;140(7):1909–18.
Efthymiou M, Taylor A, Desmond P, Allen B, Chen R. Biopsy forceps is inadequate for the resection of diminutive polyps. Endoscopy. 2011;43(4):312–6.
Lieberman D, Rex D, Winawer S, Giardiello F, Johnson D, Levin T. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on colorectal cancer. Gastroenterology. 2012;143(3):844–57.
Haggitt R, Glotzbach R, Soffer E, Wruble L. Prognostic factors in colorectal carcinomas arising in adenomas: implications for lesions removed by endoscopic polypectomy. Gastroenterology. 1985;89:328–36.
Kikuchi R, Takano M, Takagi K, Fujimoto R, Nozaki T, Fujiyoshi T, Uchida Y. Management of early invasive colorectal cancer. Risk of recurrence and clinical guidelines. Dis Colon Rectum. 1995;38(12):1286–95.
Resch A, Langner C. Risk assessment in early colorectal cancer: histological and molecular markers. Dig Dis. 2015;33(1):77–85.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2019 Springer Nature Switzerland AG
About this chapter
Cite this chapter
Huang, E., McGee, M.F. (2019). Colorectal Polyps. In: Docimo Jr., S., Pauli, E. (eds) Clinical Algorithms in General Surgery . Springer, Cham. https://doi.org/10.1007/978-3-319-98497-1_65
Download citation
DOI: https://doi.org/10.1007/978-3-319-98497-1_65
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-98496-4
Online ISBN: 978-3-319-98497-1
eBook Packages: MedicineMedicine (R0)