Advanced Endoscopic Resection of Colorectal Lesions

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Key points

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    Advanced endoscopic resection techniques represent the most cost-effective option for the management of difficult colorectal lesions.

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    Proficiency in optical diagnosis, techniques to prevent complications and to resect are key to the management of complex colorectal lesions.

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    All the team members should fully understanding the techniques and equipment needed to perform them.

Characterization of NP-CRN

Endoscopic characterization of the colorectal lesion is the first step in the assessment of whether a lesion is a candidate for curative endoscopic resection. This characterization can be undertaken using the shape of the lesion (macroscopic characterization) as well as the mucosal surface pit pattern and vascular pattern (microscopic characterization). Lesions amenable for curative resection are those limited to the mucosa and, perhaps, superficial submucosa, whereas those extending to deep

Resection techniques

Resection techniques to treat difficult colorectal lesions include the inject-and-cut endoscopic mucosal resection (EMR), EMR with specialized cap (EMR-C), EMR with band ligation (EMR-L), underwater EMR, endoscopic submucosal dissection (ESD), and specialized polypectomy techniques (Box 4).

Advanced resection in certain locations

Lesions located proximal to the dentate line, ileocecal (IC) valve, appendiceal orifice, and lesions behind a fold or folds may require additional techniques.

Advanced resection in chronic inflammatory bowel disease

The EMR of nonpolypoid or sessile lesions in patients with chronic inflammatory bowel disease present a special challenge because of increased risk of colorectal cancer, suppressed immune system from use of immunomodulators and steroids, difficulty in delineating the border of the lesion, and significant difficulty in capturing the lesion using a snare because of underlying fibrosis. In addition, descriptions of the technique and efficacy of endoscopic resection in patients with inflammatory

Endoscopic resections of large pedunculated lesions

Large pedunculated lesions in the colon and rectum include polyps arising from the mucosa and those arising from the submucosa (lipoma). These lesions can easily be differentiated by examining the mucosal pattern of the head of the polyp, which is abnormal for the mucosal lesions and normal for the lipomas. Prevention of complications is critical in the resection of both types of lesions.

EMR of rectal carcinoids using band ligation

Band ligation for endoscopic resection of adenomas has been performed in the rectum with good results.36, 37 Because of the thinness of the colon wall, the use of band ligation has been deemed unsafe.

Complications

The main complications are bleeding and perforation. Bleeding should be arrested when it occurs, using a dedicated hot coagulation forceps, hot biopsy forceps, or APC for minor bleeding. When large vessels are present or the bleeding cannot be arrested using coagulation, we use endoscopic clips to ligate the bleeding vessels. Perforations occur in 0.1% of therapeutic colonoscopies. Precautions to avoid perforations include applying the snare on the stalk away from the wall in pedunculated

Repeat Colonoscopy

Follow-up colonoscopy should be performed 3 to 6 months after piecemeal EMR to assess resection completeness and remove any residual or recurrent lesion.39 High-definition endoscopes are preferred. We look for the scar of prior resection, which can be recognized by the mucosal changes or the presence of a tattoo. The area should be studied under white light and image-enhanced endoscopy techniques as previously detailed. If the area shows no signs of local macroscopic recurrence, then targeted

Summary

Advanced endoscopic resection techniques allow curative treatment of difficult colonic lesions and avoid the need for surgery in certain cases. If endoscopic resection is indicated, the choice of the most appropriate resection technique depends on lesion characteristics and endoscopist expertise.

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