MANAGING THE DIFFICULT I have the following financial relationships - - PDF document

12/11/2012 1

MANAGING THE DIFFICULT POLYP

Steve H. Erdman, MD Division of Gastroenterology, Hepatology and Nutrition N ti id Child ’ H it l Nationwide Children’s Hospital The Ohio State University College of Medicine Columbus, Ohio

I have the following financial relationships to disclose:

Cancer Prevention Pharmaceuticals, Inc. *

• consultant, research grant support

Abbott Labs, Inc. *

• consultant

* Products or services produced by this company are NOT relevant to my presentation and will not be discussed.

Objectives

• 1. To review the clinical significance & management
• f gastric, small bowel and colon polyps

2 To review current therapeutic methodology for

• 2. To review current therapeutic methodology for

polyp removal

• 3. To discuss methods to optimize polyp removal

and recovery with a focus on safety

SO WHY DO WE REMOVE POLYPS?

• ADULT perspective (sporadic adenomas):

– Complete oncologic resection (disruption of the adenoma-to- carcinoma sequence) – Polypectomy leads to reduction in the incidence of CRC – Polyp type or tissue diagnosis based on histology (tissue retrieval!)

• PEDIATRIC perspective:

– Tissue diagnosis – Therapeutic intervention to treat bleeding, pain, polyp prolapse, intussusception risk – Cancer risk not as great in the pediatric age group

POLYP TYPES

• PEDUNCULATED

polyp with a stalk, stem or pedicle

• SESSILE

elevated broad-based lesion without a pedicle

• FLAT

level or slightly raised lesion

What is a Difficult Polyp?

Any polyp that confounds removal and/or retrieval

• SIZE: large (vascular supply) or small (retrieval)
• SHAPE: lobulated, laterally spreading, large/broad pedicle or flat
• LOCATION: with poor visualization and access: right colon/cecum,

angulated portion of the colon, haustral folds, post surgical anatomy

– Stomach: size, location – Small intestine: narrow lumen peristalsis – Small intestine: narrow lumen, peristalsis

• NUMBER: (complications increase with the number & complexity)
• NON-IDEAL SETTING: poor prep, inadequate sedation, lack of

appropriate accessories or equipment

Greater risk of complications

Mönkemüller K. et al. Dig Dis, 2008 Vormbrock World J Gastrointest Endosc, 2012

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The POLYPECTOMY DANCE

GOALS:

Remove the polyp, achieve hemostasis, no complication

1.Heat causing cauterization 2.Shearing force from snare closure

• Joint application of both interventions to accomplish a clean bloodless

polypectomy without deep thermal bowel wall damage p yp y p g

• “The delivery of energy should be continuous once polypectomy has

commenced, and the person who closes the snare should do so slowly” Jerome D. Waye

ANTICIPATION

• Informed consent: risks for bleeding, perforation or missed pathology
• Bowel prep
• Discontinuation of NSAIDS, anticoagulants (patient specific)

POLYP REMOVAL

Polyp-Endoscope Orientation

• Rotation of the endoscope to place the polyp at the bottom of the

field of vision (5-6 O’clock position)

• Location of the suction/accessory channel - optimal visualization

Improving the View or Approach Improving the View or Approach

• Application of abdominal pressure
• Change patient position
• Retroflexion of the scope
• Double lumen instrument with use of an accessory as a stint or with

tri-pronged grasper to manipulate the polyp into the snare

• Double scope and endoscopist technique
• Peristalsis/spasm: IV glucagon

(<20 kg: 0.5 mg or 20-30 mcg/kg/dose; ≥20 kg: 0.25-2 mg)

Electrosurgery

Use of high-frequency electric current to generate heat

• Bipolar: voltage is applied using paired (+ & -) similarly-

sized electrodes, effect occurring between electrodes

• Monopolar: Active electrode(focused current density) with a

return pad electrode (diffuse current density) current goes through the patient

• Cut: high heat that vaporizes

tissue (risk: immediate bleeding)

• Coagulate: heat generation

(risk: delayed bleeding, transmural injury/perforation)

• Blend: features of both

www.valleylab.com/education/poes/poes_10.html

KNOW YOUR EQUIPMENT

• Firm tight connections
• Monitor for tissue response: start low - go high
• Short bursts: don’t stand on the pedal
• Bleeding can be

addressed

• Full thickness burn

means surgery

The Polyp Snare

• Snare is deployed beyond the polyp and pull back onto it
• Tip of the Snare sheath is positioned at polyp base as

snare is closed with reduction of air in the lumen (reduced wall tension, increase thickness in wall under polyp)

• For pedunculated polyps place the snare half way
• For pedunculated polyps place the snare half way

between the wall and polyp: leave a stalk

• Withdrawal or “tent” the polyp & snare into the lumen
• Avoid contact with bowel wall, residual stool or fluid

(short circuit preventing coagulation while injuring unintended areas)

“Cold” Snare Removal

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Polyp Trap Injection Assisted Polypectomy Saline Lift Method

• Injection of a material to create a submucosal cushion
• Separates muscularis mucosa from m. propria/serosa

Reduced risk of thermal injury to deeper layers of the Reduced risk of thermal injury to deeper layers of the bowel

• Exerts a tamponade effect on blood supply allowing for

deeper/more complete resection

• Needle should approach mucosa at a 30º angle, enter the

base of the polyp tangential to the surrounding mucosa

Injection Assisted Polypectomy Saline Lift Method

• Multiple slow gradual injections (saline) into polyp base

during needle withdrawal

• Diluted epinephrine(1:100 000): vasoconstriction & polyp
• Diluted epinephrine(1:100,000): vasoconstriction & polyp

shrinkage Epinephrine Volume Reduction EVR (Hogan technique)

• Other materials: dextrose, dye, sodium hyaluronidase, fibrinogen

hydroxypropyl methylcellulose

• Endoscopic Mucosal Resection(multiple cuts) (EMR)
• Endoscopic Submucosal Dissection (ESD)

Hemangioma Removal Piecemeal Resection or Polypectomy

• Lesions too large or lobulated to allow for

complete snaring with one pass

• Polyp is retrieved in pieces

Polyp is retrieved in pieces

Preventing/Controlling Complications

Endoloop

http://www.gastrohep.com/images/image.asp?id=1156

Endoclip

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Polyp Retrieval

• Through the scope
• Retrieve with snare or basket
• Secure polyp to the scope using suction
• “Relay removal” polyp/fragment transfer

from one location to another

• Use of an overtube

SURGERY

Minimally Invasive Approaches

• Laparoscopic–assisted endoscopic polypectomy

Surgeon maneuvers the colon to improve visualization and access

Laparoscopic assisted colectom

• Laparoscopic–assisted colectomy

Polyps that: extend into the IC valve, or appendix, involve more than 30% of the colonic circumference

• Risk assessment: hepatic flexure, right colon and cecum

Segmental or wedge resection

Follow up instructions for patients and families

• Warning signs of perforation or bleeding

(early and late) ? R t i t ti it t d i t

• ? Restrict activity to reduce intra

abdominal pressure on weakened area of the bowel

• ? Delay restarting of warfarin/ aspirin

/NSAIDs for 10 - 14 days

ANTICIPATION & PLANNING

• Have supplies and accessories ready

– Polyp snares in multiple sizes (hot & cold) – Polyp snares in multiple sizes (hot & cold) – Injector needles with epinephrine, saline, dye – Retrieval baskets – Polyp traps – Endoclips – Endoloops

• KNOW YOUR EQUIPMENT!
• Have a colleague handy