Large sessile colonic adenomas: use of argon plasma coagulator to supplement piecemeal snare polypectomy

doi:10.1016/S0016-5107(99)70291-9

Gastrointestinal Endoscopy

Volume 49, Issue 6, June 1999, Pages 731-735

https://doi.org/10.1016/S0016-5107(99)70291-9 Get rights and content

Abstract

Background: Residual adenoma is frequently found at the site of endoscopically resected large sessile adenomas on follow-up examination. We evaluated the efficacy of a thermal energy source, the argon plasma coagulator, to destroy visible residual adenoma after piecemeal resection of sessile polyps. Methods: Seventy-seven piecemeal polypectomies with or without the use of argon plasma coagulator were analyzed retrospectively. All polyps were sessile, 20 mm or greater in size. The results from three groups of patients were compared. The study group was composed of patients who had visible residual adenoma after piecemeal polypectomy and had the base of the polypectomy site treated with the argon plasma coagulator. The first comparison group consisted of patients who underwent standard piecemeal polypectomy in whom the colonoscopist thought that all adenomatous tissue was removed and no further treatment was necessary. The second comparison group included patients in whom visible residual adenoma was left at the base after piecemeal resection of large adenomas. Follow-up colonoscopy was performed approximately 6 months after the initial procedure to check for recurrent/residual adenomatous tissue. Results: The argon plasma coagulator was used after 30 piecemeal polypectomies in an attempt to eradicate visible residual adenomatous tissue; at follow-up, 50% of these cases had complete eradication of adenoma. The group in whom all visible tumor was removed by piecemeal polypectomy alone had an adenoma eradication rate of 54% on follow-up colonoscopy. In the patients in whom visible residual adenoma was left at the site the recurrence rate was 100% on the follow-up examination. Bleeding necessitating endoscopic therapy occurred once (3.3%) in the argon plasma coagulator group; there were four (12.5%) bleeding episodes and one (3.1%) confined retroperitoneal perforation in the complete piecemeal polypectomy group and no complications in the group in which polypectomy was incomplete. Conclusions: Argon plasma coagulator ablation of residual adenomatous tissue at the polypectomy base is safe and useful. It helps to complete the eradication of large sessile polyps when there is visible evidence of residual polyp. (Gastrointest Endosc 1999;49:731-5.)

Section snippets

PATIENTS AND METHODS

Over a period of 2 years outcomes of all polypectomies of large colorectal adenomas performed with or without the assistance of the APC were collected, with all data recorded for each patient immediately after polypectomy. The results were analyzed retrospectively. The electrosurgical unit employed was a Valleylab surgistat (Boulder Colo.), using pure coagulation current at a dial setting of 3. All snares used were manufactured by Wilson-Cook, Inc. (Winston-Salem, N.C.). Because of our

RESULTS

Outcomes for the three study groups are summarized in Table 1.

. Outcomes of polypectomy of large colorectal adenomas performed with APC-assisted versus standard technique

Piecemeal polypectomy	APC group	Comparison group without visible residual polyp	Comparison group with visible residual polyp
No. of patients	30	32	10
No. of polyps	30	37	10
Average polyp size (mm)	32.2	28.4	30.0
Months to follow-up colonoscopy	5.5	7.1	6
Recurrence at follow-up	15 (50%) (1)	17 (46%)^*	10 (100%) (2)
Complications (perforation)	0	1 (3.1%)^†	0

DISCUSSION

Piecemeal polypectomy of large sessile colorectal adenomas has a rate of recurrent/residual polyp at the polypectomy site that ranges from 16% to 46% in different series.1, 2, 3, 4, 5, 6 Recurrences are often found after a “clean colon” status was obtained, which often required more than one colonoscopy.

There is a paucity of reports on eradication of residual adenomatous tissue after piecemeal polypectomy to prevent recurrences.⁷ There are none on the use of monopolar electrocautery, multipolar

References (34)

KF Binmoeller et al.
Endoscopic snare excision of “giant” colorectal polyps
Gastrointest Endosc
(1996)
S Nivatvongs et al.
Piecemeal snare excision of large sessile colon and rectal polyps: is it adequate?
Gastrointest Endosc
(1984)
JD. Waye
How big is too big?
Gastrointest Endosc
(1996)
GD De Palma et al.
Endoscopic treatment of sessile rectal adenomas: comparison of Nd:YAG laser therapy and injection assisted piecemeal polypectomy
Gastrointest Endosc
(1995)
T Kanamori et al.
Injection-incision-assisted snare resection of large sessile colorectal polyps
Gastrointest Endosc
(1996)
E Brand et al.
Electrosurgical debulking of ovarian cancer: a new technique using the argon beam coagulator
Gynecol Oncol
(1990)
DM Quinlan et al.
Application of argon beam coagulation in urological surgery
J Urol
(1992)
R Chutkan et al.
The argon plasma coagulator: a new and effective modality for treatment of radiation proctitis
Gastrointest Endosc
(1997)
SK Heier et al.
Argon plasma coagulation: comparison to other candidate therapies for Barrett's ablation using the canine esophagus [abstract]
Gastrointest Endosc
(1997)
J Regula et al.
Endoscopic argon plasma coagulation (APC) after piecemeal polypectomy of colorectal adenomas: two-year follow-up study
Gastrointest Endosc
(1997)

JP. Christie

Colonoscopic excision of large sessile polyps

Am J Gastroenterol

(1977)

O Kronborg et al.

Follow-up after colorectal polypectomy, II: repeated examinations of the colon every 6 months after removal of sessile adenomas and adenomas with the highest degrees of dysplasia

Scand J Gastroenterol

(1983)

G Bedogni et al.

Colonoscopic excision of large and giant colorectal polyps: technical implications and results over eight years

Dis Colon Rectum

(1986)

RM Walsh et al.

Endoscopic resection of large sessile colorectal polyps

Gastrointest Endosc

(1992)

DE Low et al.

Nd-YAG laser photoablation of sessile villous and tubular adenomas of the colorectum

Ann Surg

(1988)

G Farin et al.

Argon plasma coagulation in flexible endoscopy: the physical principle

Endosc Digest

(1998)

CM Dunham et al.

The role of the argon beam coagulator in splenic salvage

Surg Gynecol Obstet

(1991)

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^☆: Reprint requests: Jerome D. Waye, MD, 650 Park Ave., New York, NY 10021.

^☆☆: 37/1/97779

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Large sessile colonic adenomas: use of argon plasma coagulator to supplement piecemeal snare polypectomy☆,☆☆

Abstract

Section snippets

PATIENTS AND METHODS

RESULTS

DISCUSSION

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gynecol Oncol

J Urol

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Colonoscopic excision of large sessile polyps

Am J Gastroenterol

Follow-up after colorectal polypectomy, II: repeated examinations of the colon every 6 months after removal of sessile adenomas and adenomas with the highest degrees of dysplasia

Scand J Gastroenterol

Colonoscopic excision of large and giant colorectal polyps: technical implications and results over eight years

Dis Colon Rectum

Endoscopic resection of large sessile colorectal polyps

Gastrointest Endosc

Nd-YAG laser photoablation of sessile villous and tubular adenomas of the colorectum

Ann Surg

Argon plasma coagulation in flexible endoscopy: the physical principle

Endosc Digest

The role of the argon beam coagulator in splenic salvage

Surg Gynecol Obstet