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

12/11/2012 MANAGING THE DIFFICULT I have the following financial relationships POLYP to disclose: Steve H. Erdman, MD Cancer Prevention Pharmaceuticals, Inc. * Division of Gastroenterology, Hepatology and Nutrition -consultant, research grant support N ti Nationwide Children’s Hospital id Child ’ H it l The Ohio State University College of Medicine Abbott Labs, Inc. * Columbus, Ohio -consultant * Products or services produced by this company are NOT relevant to my presentation and will not be discussed. Objectives SO WHY DO WE REMOVE POLYPS? • ADULT perspective (sporadic adenomas): 1. To review the clinical significance & management – Complete oncologic resection (disruption of the adenoma-to- of gastric, small bowel and colon polyps carcinoma sequence) – Polypectomy leads to reduction in the incidence of CRC – Polyp type or tissue diagnosis based on histology (tissue retrieval!) 2 To review current therapeutic methodology for 2. To review current therapeutic methodology for polyp removal • PEDIATRIC perspective: – Tissue diagnosis – Therapeutic intervention to treat 3. To discuss methods to optimize polyp removal bleeding, pain, polyp prolapse, and recovery with a focus on safety intussusception risk – Cancer risk not as great in the pediatric age group What is a Difficult Polyp? POLYP TYPES • PEDUNCULATED Any polyp that confounds removal and/or retrieval polyp with a stalk, stem or pedicle • SIZE : large (vascular supply) or small (retrieval) • SESSILE • SHAPE : lobulated, laterally spreading, large/broad pedicle or flat elevated broad-based lesion without a • LOCATION : with poor visualization and access: right colon/cecum, pedicle angulated portion of the colon, haustral folds, post surgical anatomy – Stomach: size, location • FLAT – – Small intestine: narrow lumen peristalsis Small intestine: narrow lumen, peristalsis level or slightly raised lesion • 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 1

12/11/2012 The POLYPECTOMY DANCE POLYP REMOVAL GOALS: Polyp-Endoscope Orientation Remove the polyp, achieve hemostasis, no complication • Rotation of the endoscope to place the polyp at the bottom of the 1.Heat causing cauterization field of vision (5-6 O’clock position) 2.Shearing force from snare closure • Location of the suction/accessory channel - optimal visualization • Joint application of both interventions to accomplish a clean bloodless Improving the View or Approach Improving the View or Approach polypectomy without deep thermal bowel wall damage p yp y p g • “The delivery of energy should be continuous once polypectomy has • Application of abdominal pressure commenced, and the person who closes the snare should do so • Change patient position slowly” Jerome D. Waye • Retroflexion of the scope ANTICIPATION • Double lumen instrument with use of an accessory as a stint or with tri-pronged grasper to manipulate the polyp into the snare • Informed consent: risks for bleeding, perforation or missed pathology • Double scope and endoscopist technique • Bowel prep • Peristalsis/spasm: IV glucagon • Discontinuation of NSAIDS, anticoagulants (patient specific) (<20 kg: 0.5 mg or 20-30 mcg/kg/dose; ≥ 20 kg: 0.25-2 mg) Electrosurgery KNOW YOUR EQUIPMENT Use of high-frequency electric current to generate heat • Firm tight connections • Bipolar: voltage is applied using paired (+ & -) similarly- • Monitor for tissue response: start low - go high sized electrodes, effect occurring between electrodes • Short bursts: don’t stand on the pedal • Bleeding can be • Monopolar: Active electrode (focused current density) with a addressed return pad electrode (diffuse current density) current goes • Full thickness burn through the patient means surgery o Cut: high heat that vaporizes tissue (risk: immediate bleeding) o Coagulate: heat generation (risk: delayed bleeding, transmural injury/perforation) o Blend: features of both www.valleylab.com/education/poes/poes_10.html “Cold” Snare Removal 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) 2

12/11/2012 Injection Assisted Polypectomy Polyp Trap 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 Hemangioma Removal 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) Preventing/Controlling Piecemeal Resection or Complications Polypectomy • Lesions too large or lobulated to allow for Endoloop complete snaring with one pass • Polyp is retrieved in pieces Polyp is retrieved in pieces http://www.gastrohep.com/images/image.asp?id=1156 Endoclip 3

12/11/2012 SURGERY Polyp Retrieval Minimally Invasive Approaches • Through the scope • Laparoscopic–assisted endoscopic polypectomy Surgeon maneuvers the colon to improve visualization and access • Retrieve with snare or basket • Laparoscopic–assisted colectomy Laparoscopic assisted colectom • Secure polyp to the scope using suction Polyps that: extend into the IC valve, or appendix, involve more than 30% of the colonic circumference • “Relay removal” polyp/fragment transfer from one location to another • Risk assessment: hepatic flexure, right colon and cecum Segmental or wedge resection • Use of an overtube Follow up instructions for ANTICIPATION & PLANNING patients and families • Warning signs of perforation or bleeding (early and late) • Have supplies and accessories ready – Polyp snares in multiple sizes (hot & cold) – Polyp snares in multiple sizes (hot & cold) • ? Restrict activity to reduce intra ? R t i t ti it t d i t – Injector needles with epinephrine, saline, dye abdominal pressure on weakened area of – Retrieval baskets the bowel – Polyp traps – Endoclips – Endoloops • ? Delay restarting of warfarin/ aspirin • KNOW YOUR EQUIPMENT! /NSAIDs for 10 - 14 days • Have a colleague handy 4