Difficult Polypectomy 2015 Tool of the Trade

Difficult Polypectomy 2015 Tool of the Trade Jonathan Cohen, MD FACG FASGE Clinical Professor of Medicine NYU Langone School of Medicine Improving Therapeutics in the Colon Improved detection of polyp and polyp margins Improved resection techniques Improved closure of iatrogenic mucosal defects Copyright 2015 American College of Gastroenterology 1

Therapeutic Tips & Considerations Generous use of saline lift Epi injection to thick bases and stalks Suction to reduce diameter Recognize non-lifting and signs of invasive i cancer Fulgurate the base of sessile polyps Therapeutic Tips & Considerations Carefully image the margins to ensure complete resection Insist on comfortable short scope positions with torque to get lesion in ideal location Creation of leading edges for piecemeal polypectomy Suction to small flat lesions to facilitate t removal Consideration of clips to close larger defects Copyright 2015 American College of Gastroenterology 3

Polypectomy Piece by Piece EMR Effective if Done Right Moss, A., Williams, S.J., Hourigan, L.F. et al. Longterm adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut. 2015; 64: 57 65 Care to excise normal mucosa around lateral margin 97% success rates in <2 sessions Copyright 2015 American College of Gastroenterology 4

Efficacy of wemr ACE [Australian Colonic EMR] Study Prospective study of flst >20 mm with f/u exams at 4 and 12 months 940 cases, successful excision in 91% 81% no recurrence at 4 months; 0.6% at 12 mo. 19% diminutive i and generally easy to remove recurrence; only 3 persisted at 12 mo. Only 1 patient required surgery 120 mm sized laterally spreading tumor of the proximal transverse colon from ACE study Copyright 2015 American College of Gastroenterology 5

Should we clip large resection sites together? Video Rationale for Closure Clips cost effective only for polyps >10 mm in anticoagulated patients: Parikh, N.D., Zanocco, K., Keswani, R.N. et al. Acost- efficacy decision analysis of prophylactic clip placement after endoscopic removal of large polyps. Clin Gastroenterol Hepatol. 2013; 11: 1319 1324 Prophylactic clip closure reduced the risk of delayed ed postpolypectomypectom hemorrhage: experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions: Hammad Liaquat, Elizabeth Rohn, Douglas K. Rex Gastrointestinal Endoscopy, Vol. 77, Issue 3, p401 407 Copyright 2015 American College of Gastroenterology 6

Obstacles to Successful Large EMR Fibrosis [suggested by non-lifting] Prior biopsy or partial polypectomy Tatooing close to the lesion Imaging evidence suggestive of cancer Location right colon; multiple folds, flexures Approaches to Non-Lifting, Fibrosis, and Residual Tissue Water jet assisted lifting Avulsion technique to remove non-lifting mucosal bridges Endocut via HBF Underwater polypectomy Cap assisted gentle suction with great care! Hybrid ESD techniques combined with piecemeal EMR Copyright 2015 American College of Gastroenterology 7

Extreme Polypectomy: ESD Colon ESD Considerations High perforation rates: 2.7% in Japanese series Dependent on available local expertise Potential reduced recurrence of large laterally spreading tumors [LST s] Saito Y et al. Surg Endosc 2010; 24:343-52 2% vs. 14% recurrence rate Improved histologic assessments when 1 micron of sm1 might suffice without surgery Copyright 2015 American College of Gastroenterology 8

When to consider ESD Large LST granular type >30 mm Large LST non granular >20 mm Non lifting sign Imaging suggestion of advance histology or submucosal invasion: Kudo V Sano 3 Image of ESD small defects Copyright 2015 American College of Gastroenterology 9

Damage Control Bowel prep ensure a clean field before embarking on colon EMR C02 insufflation reduces pneumoperitoneum Immediate recognition target target sign If you think it might be a perforation assume it is and close it! Target sign accentuated by use of dye in submucosal injection Copyright 2015 American College of Gastroenterology 11

TIPS FOR CLIPS Keep the clip close to the end of the endoscope with the clip-endoscope acting as a single unit. Position the wide-open clip across the defect at 90 degrees to the defect. Gently push the clip-endoscope unit as one unit while applying gentle suction to collapse the lumen so that as much tissue away from the edge of perforation as possible could be grasped while slowly closing the clip. More Tips for Clips Confirm satisfactory clip closure of the perforation with approximation of the edges before deployment of the clip. Be patient while applying a clip because a misplaced clip to one edge of the perforation could lead to difficulty in applying additional clips for satisfactory closure. Copyright 2015 American College of Gastroenterology 13

Tips for Clips 3 Place additional clips from top-todown in linear perforations or left-to- to right in circular perforations after satisfactory application of the first clip, which is the most critical component of closure. Consider pinch just lateral l to edge of defect to bring sides closer together Copyright 2015 American College of Gastroenterology 14

Clip Caveats I. Avoid panic. Be calm and steady for proper use of the equipment by you and your assistant. Keep the endoscope close to the site of perforation Distance will interfere with proper clip control Minimize i i air insufflation Clip Caveats II. Avoid stretching the tissue by pushing the clip against the wall as this limits successful approximation of the edges together. Avoid hasting deployment of the first clip without checking that both the edges were successfully approximated as this will result in a wasted deployment to one edge of the perforation without complete tissue apposition of both edges of perforation. Copyright 2015 American College of Gastroenterology 16

Overstitch closure Special Imaging Considerations for Colon EMR Recognizing lesions containing high grade dysplasia that t will require good submucosal lift Detection serrated lesions Detecting margins for complete polypectomy Copyright 2015 American College of Gastroenterology 18

What about SSA detection? Beyond Polyp Recognition-Complete Resection Potential ti future key quality targett Advanced imaging may lead to improvement Copyright 2015 American College of Gastroenterology 20

Delineation of Margins: Can OCE Help us Leave Less Behind? Optical contrast appears to facilitate recognition of borders. Data confirming that optical contrast assisted resection reduces incomplete polypectomy rates has yet to be obtained. Demarcation of Margins: Duodenal Adenoma Copyright 2015 American College of Gastroenterology 21

Poor Margin Assessment Leads to Poor Outcome: Incomplete polypectomy U of Minnesota: 27% of interval cancers Sawhney Gastro 2006;131:1700-5 Pink Rim Accentuates Polyp Margins Copyright 2015 American College of Gastroenterology 22

Imaging Critical to Improve Complete Resection 1. Type 3 mucosal and vessel pattern requires saline EMR or ESD to ensure deep margin 2. Lateral margin delineation assistance Low Tech Margins Assessment Small amounts of contrast dye indigo carmine added to saline cushion may separate pits and facilitate examination of margins post-polyp resection Copyright 2015 American College of Gastroenterology 23

The Iceberg Effect NBI Reveals Flat Adenomatous Projections of Polyp Visible on White Light Polypectomy of Tubular Adenoma Post-polypectomy inspection of polyp border: normal pit pattern confirms complete resection Copyright 2015 American College of Gastroenterology 24

Accentuation of Normal Pit Pattern to Confirm Clear Margins Putting All the Tools Together: 69-year-old male presented with depression, mild weight loss and chronic constipation without blood No prior colorectal screening Normal CBC, iron studies, metabolic panel No family history of GI cancer Copyright 2015 American College of Gastroenterology 25

Cap Fitted Colonoscopy Kondo S. et al Am J Gastro 2007;102:75-81. Increased overall polyp detection 49.3% vs 39.1% p< 0.05 Decreased cecal intubation time NBI Characterization Anterograde Copyright 2015 American College of Gastroenterology 29