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4 Endoscopy
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Endoscopic Management ofPolyps
andEndolumenal Surgery
WilliamForrestJohnston andEmreGorgun
5
Abbreviations
ESGE European Society of GI Endoscopy
EMR Endoscopic mucosal resection
ESD Endoscopic submucosal dissection
CELS Combined endoscopic-laparoscopic surgery
ELS Endolumenal surgery
Key Concepts
• Endolumenal surgery is the forefront of minimally invasive surgery and is rapidly developing.
• Colon and rectal surgeons should be involved in the progression of endolumenal surgery as it will offer benet to
patients.
• New endolumenal techniques can be used to address large
polyps that once required resection and treat malignant
large bowel obstructions.
Introduction
Colonoscopy was initially described as a way to screen
patients for mucosal abnormalities in the colon and has been
adopted as the standard for colorectal cancer screening and
prevention. However, when retrograde colonoscopy was rst
described in 1969, “there were some who said it couldn’t be
done, shortly followed by those who said it couldn’t be done
safely, followed by those who declared that it required a tricky
W. F. Johnston
Ochsner Clinic, Department of Colon and Rectal Surgery,
New Orleans, LA, USA
E. Gorgun (
Cleveland Clinic, Department of Colorectal Surgery,
Cleveland, OH, USA
e-mail: gorgune@ccf.org
*)
skill which few would be able to acquire” [1]. Time has proved
otherwise. Colonoscopic polypectomy has been demonstrated
to decrease the incidence of colorectal cancer and has been
widely adopted by the medical community [2]. With advances
in technology, colonoscopy has progressed dramatically, and
exible colonoscopy is now used with various platforms that
enable advanced endoscopic surgical procedures to be effectively completed. Endolumenal surgery is a rapidly progressive eld in gastrointestinal surgery performed by both
surgeons and gastroenterologists that offers the benets of
non-invasive surgery done in an outpatient setting. However,
endolumenal surgeons are confronted with the challenge of
operating through a exible scope in a conned space that is
frequently moving. Similar to opponents of early colonoscopy, there are many physicians in various stages of opposition. Due to the benets to the patient, endoscopic surgery has
the potential to be the next leap forward in minimally invasive
surgery. This chapter will discuss the technical aspects of
endolumenal surgery, ranging from forceps polypectomy to
endoscopic submucosal dissection and colonic stenting.
Forceps
There are three commonly available options for forceps polypectomy: cold biopsy forceps, jumbo cold biopsy forceps, and
hot biopsy forceps. For cold biopsy, the standard forceps open
to 6 mm, and jumbo cold forceps open to 8.6 mm. Jumbo
biopsy forceps have been shown to be superior to standard cold
forceps for complete resection [3]. Historically, hot biopsy forceps were commonly used for polyp resection with the theoretical benet of fulgurating any remaining dysplastic tissue
around the polyp. However, this theoretical advantage has been
refuted. A retrospective review of 62 hot biopsy polypectomies
demonstrated a 17% rate of persistent polypoid tissue on repeat
endoscopy 1–2weeks after the original treatment [4].
Additionally, hot biopsy is associated with an increased
risk of delayed hemorrhage compared to cold biopsy [5].
© Springer Nature Switzerland AG 2022
S. R. Steele et al. (eds.), The ASCRS Textbook of Colon and Rectal Surgery, https://doi.org/10.1007/978-3-030-66049-9_5
79
80
W. F. Johnston and E. Gorgun
Furthermore, hot biopsy alters the polyp morphology and
creates more histological architectural distortion and fragmentation than cold biopsy [6]. For the aforementioned reasons, the European Society of GI Endoscopy (ESGE) has
recommended against the use of hot biopsy forceps [7].
Cold biopsy forceps have also been described as an
adjunct to difcult to remove large spreading polyps. While
these polyps are typically removed with snare (described
below), some polyps will not allow snare resection as the
snare will slide over the polyp. In these situations, cold forceps are used to methodically avulse all visible polypoid tissue. Following avulsion of the mucosa, the submucosa and
margins can be treated with soft coagulation from the tip of
a hot snare. This technique, deemed CAST for Cold-forceps
Avulsion with adjuvant Snare-Tip soft coagulation, has been
reported as an effective and safe strategy for the management
of non-lifting large laterally spreading (LST) colonic lesions
[8]. CAST is easy to use, does not require additional equipment, and is useful adjunctive technique for organ sparing.
Snare
Endoscopic snare allows resection of larger lesions and more
tissue compared to forceps. Incomplete resection of polyps
by any method is associated with interval development of
colorectal cancer in patients undergoing colonoscopy [9]. In
removal of polyps <6mm, snare excision has a higher rate of
complete resection compared to forceps removal (93% for
cold snare vs. 76% for cold biopsy forceps, p<0.001) [10].
Snares vary in size, shape, and ability for coagulation.
Hot snares are the traditional method for endoscopic snaring
but have waned in popularity over recent years due to complications including increased risk of delayed bleeding and
thermal injury. Use of a cold snare without electrocautery is
associated with lower rate of post-polypectomy hemorrhage
and shorter time for polypectomy and colonoscopy [11, 12].
Complete resection rates with cold snare are equivalent to
hot snare [13]. Dedicated cold snares have been further
improved with use of a thinner wire that more easily cuts tissue. Compared to traditional snares used without cautery,
dedicated thin-wire cold snares have a higher rate of complete resection, especially with polyps 8–10mm in size or
sessile polyps [14]. The 2017 guidelines from ESGE recommend cold snare polypectomy as the preferred method for
polyps <5mm in size and strongly favor cold snare polypectomy for polyps 6–9mm in size [7]. Hot snare polypectomy
has been reserved for sessile polyps 10–19mm in size after
submucosal injection has been used to decrease the risk of
thermal injury. Hot snare is also recommended for pedunculated polyps to decrease the rate of bleeding.
Bleeding after polypectomy is infrequent but may result
in hospitalization, repeat colonoscopy, and poor patient
experience. The rate of bleeding after polypectomy is
approximately 1–2 per 1000 patients and is 10 times the rate
of bleeding compared to colonoscopy without polypectomy
[15]. Bleeding after cold snare polypectomy tends to be
immediate and can be addressed at the time of initial colonoscopy, while bleeding after hot snare is often delayed and
not apparent at the initial colonoscopy. Bleeding after hot
snare occurs 0.1–0.7% of polypectomies and can occur up to
30days after the procedure [16]. Prophylactic clip placement
after routine polypectomy does not decrease the risk of
delayed bleeding [17], and this practice should be avoided as
it drastically increases the cost of the procedure without substantial benet. Selective use of endoscopic clips is discussed
later in the chapter.
Tips forOptimal Snaring
Polypectomy is required in 30–40% of all colonoscopies. To
make polypectomy easier, the polyp should be positioned at
the bottom half of the screen because the instrument channel
on the colonoscope exits the scope at the 5 o’clock position.
Occasionally, the lesion cannot be placed in the inferior
aspect of the screen due to tortuosity of the colon or location
behind a prominent fold. In those situations, working with
the scope tip further away from the lesion may facilitate polypectomy by producing a favorable angle of attack to the
polyp. Additionally, jumbo forceps removal may be technically easier for polyps in a challenging location if the size is
small. If a snare is applicable, lesions are more easily grasped
with dedicated cold snares, since they have a thinner wire
that can grip the tissue better than an electrocautery compatible snare. If a hot snare is used after a lift for a larger lesion,
consideration should be given for use of a non-oval-shaped
snare. Snares with some angulation, like a hexagonal snare,
tend to grasp tissue better as well as have a greater proximal
opening compared to standard oval or round snares.
Figure5.1 shows different type of snares.
Care should be taken during polypectomy to ensure that
complete resection of the polyp has been performed. In a
prospective study of over 1400 patients, there was a 10% rate
of incomplete resection for polyps 5–20mm. Risk factors for
incomplete resection included larger size and sessile serrated
polyps vs. adenoma [18]. Any remaining polyp tissue after
snare polypectomy can be removed with repeat snare excision or cold forceps avulsion.
Lifting
Flat lesions may require submucosal lift to separate the
desired tissue for resection from the underlying colonic muscular wall and decrease the risk of full-thickness mechanical
Exacto (cold)
Snare
(Lasso)
Snare
Cleveland
(snare with injection needle)
5 Endoscopic Management ofPolyps andEndolumenal Surgery
Fig. 5.1 Different types of
snares (Reprinted with
permission, Cleveland Clinic
Center for Medical Art &
Photography ©2020. All
Rights Reserved)
81
Small
Standard
Oval
Lariat Snare
disruption or thermal injury from a hot snare. Common submucosal lifting agents include saline, hyaluronic acid, glycerol, dilute albumin, and proprietary gels. For most polyps,
submucosal saline injection sufces and provides a lift that
lasts approximately 3minutes [19]. Normal saline has proven
equivalent to other lifting solutions in terms of complete
resection rate, post-procedural bleeding, and postpolypectomy syndrome or perforation [20]. For more complex lesions requiring a longer resection time, a more durable
solution is desirable. Viscous solutions are often more durable and provide a more localized lift with less lateral diffusion. Multiple solutions exist, ranging from hydroxyethyl
starch (hetastarch) to more expensive proprietary solutions
like Eleview® (Medtronic, Dublin, Ireland) and ORISE®
(Boston Scientic, Marlborough, MA) that can last for over
40minutes [21].
Adequate lift is critical to allow for advanced endoscopic
techniques. Ideal injections are submucosal, but endoscopic
injections can be easily misplaced in deeper layers (subserosal or intramuscular). Addition of colored dye to the injected
solution can help delineate the submucosal layer as the overlying mucosa is thin and the color of the solution will be
readily appreciated. Correctly placed submucosal injections
Jumbo Hexagonal Needle Tip Anchor
Braided Ridge
Snare
Clinic
©2019
iSnare
tend to create more focal and taller lifts, while subserosal or
intramuscular injections will create a less prominent and
broader lift [22]. Submucosal injection can be facilitated by
starting to inject solution prior to putting the needle into the
mucosa so that the injectant will push away submucosal layers once penetrating the overlying mucosa. Alternatively, the
needle can be placed into the colon wall and then gently
withdrawn back into the submucosal layer. It is easier to create a lift when injecting in a tangential direction to the bowel
wall and avoiding injecting perpendicular to the bowel wall.
Techniques for submucosal injection are also applicable to
endoscopic tattoo placement to avoid tattoo dispersing
throughout the abdomen. If a larger area is needed to lift,
injections should be directed at the border of the prior submucosal cushion to stay in the submucosal plane (Fig. 5.2).
Submucosal lift injections can be performed in a dynamic
technique to make a taller lift. The needle placement in the
submucosa is conrmed with a small amount of injection to
demonstrate an adequate lift plane followed by a largevolume rapid injection. During the large-volume injection,
the needle and scope can be re-directed within the submucosa to generate a tall and long-lasting lift [23]. For lesions
that are on a fold, submucosal injection should start on the
82
Fig. 5.2 To perform a submucosal injection, the injection needle
should be tangential (parallel) to the mucosa. Fluid is injected as the
needle is advanced to push away the muscularis and create and submucosal expansion to lift the overlying tissue (Reprinted with permission,
Cleveland Clinic Center for Medical Art & Photography ©2020. All
Rights Reserved)
proximal/oral part of the bowel to lift the lesion toward the
scope. Lesions that do not lift may be due to entry into the
incorrect plane, scarring from past attempts at injection or
polypectomy, or related to more advanced lesions that have
invaded into the submucosa.
Endoscopic Mucosal Resection
Lesions that are too large for simple polypectomy can be
treated with endoscopic mucosal resection (EMR). EMR is
regularly used for polyps ranging from 20mm to 50mm in
size. EMR is a technique designed for sessile or at lesions
that are conned to the supercial layer of the colon wall.
The most common EMR method is the lift and cut technique,
in which the lesion is lifted with a submucosal injection followed by snare polypectomy. With expansion of the submucosal space, the polyp can be removed without injury to the
muscular layer of the bowel. The goal is to completely
remove the polyp with as few snare excisions as possible [7].
EMR is started with a submucosal injection to lift the lesion
to create space for resection. Since lesions with EMR are
often larger than simple polypectomy, a solution with a longer durability than saline is desired. The ESGE recommends
the addition of a staining dye (e.g., methylene blue or indigo
carmine) to the submucosal injection to help identify lesion
margins and deep tissue injury. The submucosal lift protects
the underlying muscularis propria while decreasing resistance in the desired resection plane. The lesion is then
resected with snare in as few pieces as possible with care to
make sure that the entire lesion is removed. A normal margin
of 2–3mm of healthy-appearing tissue should be included to
ensure complete removal. To decrease the risk of leaving
W. F. Johnston and E. Gorgun
islands of polyp tissue, piecemeal snaring should be done
sequentially with the snare aligned along the margin of the
prior resection. If there are any small remaining amounts of
polypoid tissue, these can be ablated with electrocautery or
removed with forceps. Following resection, clips can be
selectively placed for tissue approximation (Fig.5.3). Hot
snare is commonly used during EMR.However, cold snare
has also been shown to be effective for piecemeal resection
after submucosal lift for polyps up to 55mm with a low rate
of recurrent disease or complication [24].
The major drawback of EMR is that larger lesions cannot
be excised in en bloc fashion. EMR has been shown to be
safe and effective for lesions smaller than 20 mm [25].
Lesions greater than 2 cm are often excised in piecemeal
fashion, which limits the pathologic assessment of the polyp.
Piecemeal resection can theoretically allow small amounts of
polypoid tissue to remain that would result in recurrent polyp
growth. While early experience with EMR indicated recurrent polyp formation on follow-up colonoscopy in 30% of
patients [26], a recent prospective multicenter trial of 1000
EMR procedures demonstrated a lower recurrence rate (17%
overall). For smaller polyps (20mm in size), recurrence rate
was 5% [27]. Risk factors for recurrence were increased size
(OR = 8.2 for polyp >40 mm vs. 20 mm), APC usage
(OR = 2.4), and bleeding (OR = 1.6). APC usage likely
results in supercial ablation of the polyp, but does not eradicate the polyp tissue. The lack of efcacy of APC has been
conrmed with other studies evaluating APC versus avulsion
for the treatment of small amounts of residual polyp tissue
after EMR.Avulsion with hot biopsy forceps was associated
with a signicantly lower adenoma recurrence rate compared
to ablation with APC (10% recurrence with avulsion vs. 59%
recurrence with APC on follow-up colonoscopy in 1 study of
278 patients with EMR of colon lesion >2cm) [28].
Clip
While routine use of prophylactic clips after polypectomy is
discouraged due to cost, endoscopic clips can be used selectively to re-approximate mucosa after EMR or be placed on
bleeding vessels in an effort to increase hemostasis. Risk factors for post-polypectomy bleeding include large polyp size,
proximal location, use of anticoagulant or antiplatelet agents,
and the presence of multiple comorbidities [29]. In a recent
multicenter randomized control trial, endoscopic clip application to close the mucosal defects of polypectomies for
non-pedunculated polyps larger than 20mm was associated
with a decreased rate of post-polypectomy bleeding [30].
The benet of clip application was most pronounced in the
proximal colon with an absolute risk reduction of 6.3%
(9.6% bleed without clips vs. 3.3% bleed with clips,
p < 0.001). Clip application for large polyps in the distal
5 Endoscopic Management ofPolyps andEndolumenal Surgery
83
Fig. 5.3 EMR technique. (a) Large at lesion in the right colon. (b) Lift with submucosal injection. (c) Piecemeal EMR resection with snare. (d)
Endoscopic clip placement for closure
colon did not affect the rate of post-polypectomy bleeding.
Application of clips has also been shown to decrease the rate
of delayed bleeding even if complete mucosal reapproximation could not be accomplished [31]. Therefore,
consideration should be given for selective use of clips following endoscopic resection of large polyps (>2cm), particularly in the proximal colon.
underwater EMR, the air is evacuated and the lumen is lled
with 500mL to 1L sterile water. The edges of the polyp are
marked with APC.The polyp is removed in piecemeal fashion with a snare on cutting current to include all of the prior
APC marks. Any small remnant tissue is treated hot biopsy
coagulation. It is hypothesized that the water distends and
attens the colon to prevent the muscularis from being
brought into the snare excision. When compared to traditional EMR, selective groups have demonstrated that under-
Underwater EMR
water EMR allows increased complete macroscopic resection
and decreased recurrence rates [33]. Additionally, underwa-
Underwater EMR was described in 2012 as a method to
avoid submucosal injection during resection of large polyps
with EMR [32]. As described above, submucosal injection
may be in the wrong layer leading to intramuscular injection.
Furthermore, submucosal injection may make snare application more challenging as the snare may slip over the distended mucosa and not grasp the polyp. To perform
ter EMR has been used to increase rates of salvage endoscopic resection for recurrent polyps after past attempts at
endoscopic resection [34].
Underwater techniques have also been applied to endoscopic submucosal dissection (ESD) [35]. Polyp resection
while submerged in water can allow the edge of mucosa to
oat away from the submucosa and therefore improve the
84
W. F. Johnston and E. Gorgun
endoscopic view of the dissection plane. Additionally, submerging the process of ESD in uid allows greater heat dissipation, which theoretically decreases thermal injury.
Potential benets of underwater endoscopic resection must
be balanced against the increased time requirement for water
instillation.
Endoscopic Submucosal Dissection
Whereas EMR is limited in terms of size of en bloc excision,
ESD is useful for larger lesions where complete histological
evaluation is desired. ESD was rst popularized in Japan in
the 1990s for treatment of early gastric cancer. The gastric
wall is thick and therefore allows for safe submucosal dissection with a margin for error. Colonic ESD was rst described
in the early 2000s [36]. The thin wall of the colon makes
colonic ESD more challenging due to increased risk of fullthickness injury. However, the benet of ESD is a more complete resection with lower recurrence rate. In a retrospective
study of over 350 patients comparing colonic ESD and EMR,
colonic ESD has a sevenfold lower recurrence rate. However,
the complete resection of ESD comes at the cost of a nearly
vefold increased rate of perforation (6.2% ESD perforation
vs. 1.3% EMR perforation) [37].
Colonic ESD allows resection of large benign lesions that
traditionally required surgical resection. Dissection is performed in the submucosal layer under the lesion using a
dedicated electrosurgical knife. Recent studies have shown
that only 20% of polyps that were deemed endoscopically
unresectable and referred to a surgeon for resection have
invasive malignancy on nal pathology [38, 39]. The rate of
malignancy is even lower when carefully evaluating polyp
morphology (see patient selection for ESD below). Large
polyps that appeared benign to the endoscopist have less
than 10% cancer rate [40]. This data suggests that the vast
majority of patients with large benign-appearing colonic polyps can be treated adequately with endoscopic resection,
saving these patients the morbidity of a larger colon resection. Comparing ESD to laparoscopic formal resection,
patients treated with ESD had a signicantly shorter hospital
stay and decreased hospital nancial cost [41]. Complication
rates were similar, but the severity of complications was less
in the patients treated with ESD compared to surgical
resection.
ESD Complications
Prior to considering any intervention, one must be aware of
the potential complications. Similar to most endoscopic polypectomy techniques, the most common complications after
ESD are abdominal pain, bleeding, perforation, and tumor
recurrence. Post-ESD electrocoagulation syndrome is
similar to post- polypectomy syndrome and can be seen in up
to 40% of patients [42]. Post-ESD bleeding occurs in approximately 2–7% of patients [43, 44]. ESD is also associated
with a 5–20% perforation rate [45]. Risk of perforation is
associated with increased tumor size and the presence of
brosis. Perforation during ESD of lesions that are malignant can result in potential tumor seeding of the abdomen, as
evidenced from the more robust gastric cancer literature. In a
review of 22 perforations during gastric ESD, 2 patients
(9%) had peritoneal seeding [46]. Lastly, endoscopic methods at resection carry the potential for recurrence. Local
recurrence after ESD is remarkably low (approximately 1%)
[43]. Furthermore, none of the recurrences contained invasive cancer and all were adequately managed with repeat
endoscopic resection in this series.
Patient Selection forESD
Careful selection of patients for attempted EMR and ESD is
key. Procedural selection is based on the size of the tumor
and the risk of underlying carcinoma. If the lesion is <2cm,
EMR is often favored. ESD is typically reserved for lesions
>2 cm without features of malignancy. For patients where
the diagnosis is unclear, ESD is an acceptable technique for
excisional biopsy of lesions that have an increased risk of
carcinoma but should be used with caution as the risk of fullthickness injury may be increased due to distortion of the
submucosa from malignant invasion or brosis.
When doing a colonoscopy or preparing for ESD, the
potential for underlying malignancy can be assessed by
endoscopic characterization of the polyp appearance.
Appearance of the lesion is critical and can be evaluated with
one of several available classication systems, including
Paris, Kudo pit pattern, or Narrow-band Imaging International
Colorectal Endoscopic (NICE) classication. The gross
morphology of the lesion is described by the Paris pattern,
which divides lesions into polypoid vs. non-polypoid appearance. The non-polypoid supercial lesions are then divided
based on their level of protrusion into the lumen (slightly
elevated, at, slightly depressed, and excavated). There is a
clear inverse relationship between supercial lesion protrusion and the risk of submucosal invasion [47]. However,
there is signicant inter-observer variability in the classication of polyps according to the Paris system, suggesting that
a simpler three-category classication of pedunculated, elevated, or depressed may be more widely applicable [48].
Depressed lesions have an increased rate of malignancy.
Pit patterns are based on the specic arrangement of
glands in different lesions and can help determine hyperplastic vs. adenomatous vs. malignant lesions [49]. Narrowband imaging (NBI) is commonly available technology that
lters light into specic blue and green waveforms that will
highlight vessels and mucosal tissue. NBI can be used to
be suggested by an irregular vessel or surface pattern, and is often associated with atypical morphology (e.g., depressed area).
5 Endoscopic Management ofPolyps andEndolumenal Surgery
85
Type 1
Color Same or lighter than background
Vessels
Surface
Pattern
Most likely
pathology
Examples
None, or isolated lacy vessels
coursing across the lesion
Dark or white spots of uniform size,
or homogeneous absence of
pattern
Hyperplastic
Type 2 Type 3
Browner relative to background
(verify color arises from vessels)
Brown vessels surrounding white
structurs**
Ova, tubular or branched
white structure
surrounded by brown vessels**
Adenoma***
Brown to dark brown relative to
background; sometimes patchy
whiter areas
Has area(s) of disrupted or missing
vessels
Amorphous or absent surface
pattern
Deep submucosal
invasive cancer
* Can be applied using colonoscopes with or without optical (zoom) magnification
** These structures (regular or irregular) may represent the pits and the epithelium of the crypt opening.
*** Type 2 consists of Vienna classification types 3,4 and superficial 5 (all adenomas with either low or high grade dysplasia,
or with superficial submucosal carcinoma). The presence of high grade dyslasia or superficial submucosal carcinoma may
Fig. 5.4 NICE classication. NICE, NBI International Colorectal Endoscopic; NBI narrow-band imaging (Reused with permission from Hayashi
etal. [50]. Copyright © Elsevier 2013)
classify the polyp as hyperplastic, adenomatous, or malignant based on lesion color, vascular pattern, and surface pattern according to the NICE classication (Fig. 5.4) [50].
Accurate endoscopic assessment allows appropriate selection of polyps for EMR/ESD and avoidance of polyps that
are better treated with resection due to concern for underlying malignancy.
The ability of the polyp to lift after submucosal injection
has also been used to assess the potential for invasive malignancy. If tumor extends into the submucosa, the submucosa
will not expand with injection. In a study of over 270 lesions,
non-lifting sign had an overall accuracy of 95% for detecting
of 98%, positive predictive value of 80%, and negative predictive value of 95% [51]. Furthermore, inadequate lift dramatically increases the likelihood of full-thickness injury as
the submucosal layer is not expanded and there is consequently no buffer. Lesions may not lift well if there is brosis
from prior attempts at resection or if the injection is too deep
in the colon wall. The multiple reasons why a polyp will not
adequately lift may explain why endoscopic assessment is
more sensitive than the non-lifting sign for detecting invasion in at or depressed lesions. Thus, in patients where the
polyp does not lift well, there remains a role for ESD as long
as the polyp has a benign morphologic appearance.
an invasive malignancy, with a sensitivity of 62%, specicity