Endoscopic Resection Of Colonic Polyps - A Review

Endoscopic polypectomy has become standard care for the treatment of colonic polyps. While about 90% of polyps are small in size and easy to resect, a small percentage of polyps are of large size (>2 cm) and broad base and endoscopic resection is a real challenge for the endoscopist. An appropriate technique for safe removal of these large colorectal polyps has been developed and includes submucosal injection of large amounts of normal saline with diluted epinephrine and piecemeal resection. We address the importance of adding a few drops of methylene blue in the submucosally injected fluid to enhance the margins of the lesion and increase the accuracy of resection. The success rate of polypectomy of large polyps is more than 90%, while up to 10% of patients may finally require surgical treatment due to malignancy or incomplete resection. Small pieces of the polyp that remain unresected at the margins during polypectomy can be destroyed by argon plasma coagulator. Immediate bleeding after polypectomy can usually be successfully treated with diluted epinephrine injection and placement of hemoclips or loops, while delayed bleeding is rare (1%). Perforation of the bowel using this technique is very rare (0.3%). In addition, all modern and new techniques for the resection of colorectal polyps are described. Colonoscopic polypectomy is considered among the high-risk procedures to induce significant bleeding, so, prior to polypectomy, adjustment in anticoagulation is necessary. For patients with high-risk conditions for a thromboembolic event, warfarin therapy should be discontinued 3 to 5 days before the procedure. The decision to administer heparin once INR falls below the therapeutic levels should be individualized For elective high-risk procedures, temporary discontinuation of newer antiplatelet medications (such as clopidogrel), particularly if the patient is on concomitant aspirin, is desirable, preferably for 7-10 days. In the absence of a pre-existing bleeding disorder, endoscopic procedures including polypectomy may be performed in patients taking aspirin and other NSAIDS in standard doses Antibiotic prophylaxis in patients undergoing polypectomy should be limited to patients with a prosthetic valve, history of endocarditis, presence of systemic-pulmonary shunt or a synthetic vascular graft less than 1 year old.