2024 Senior Fellows Program (2nd & 3rd Year) | September 2024-Faulx

Faulx_Polyp Predicaments Tricky Removals

Pdf Summary

"Polyp Predicaments: Techniques for Tricky Removals" by Ashley L. Faulx, MD MASGE, discusses the complexities and techniques involved in polyp removal. Tricky polyps are often characterized by features such as large size, flatness, challenging accessibility, scarring, previous partial resections, and improperly injected tattoos.<br /><br />Common pitfalls in polyp removal include partial snare resection, tattooing the lesion, incomplete Endoscopic Mucosal Resection (EMR), and wrongly differentiating between benign and malignant polyps. A thorough inspection before attempting resection is crucial to avoid unnecessary surgeries for benign polyps, which remain common in the U.S. despite advanced techniques. Surgery, often more expensive and associated with higher morbidity and mortality, is frequently performed in urban teaching hospitals.<br /><br />Basic techniques for successful polyp removal include achieving a straight scope position, positioning the lesion properly, potential use of a clear cap, avoiding pediatric scopes, and careful consideration of injection quality and timing. Specific techniques for challenging polyps include basic inject and snare methods, both hot and cold snaring, underwater EMR, snare tip anchoring, avulsion techniques, Cap EMR, Full Thickness Resection Device (FTRD), and Endoscopic Submucosal Dissection (ESD).<br /><br />The "Non-lifting Sign" technique involves precise injection methods to create a submucosal bleb, ensuring effective lesion lifting. Techniques like hot avulsion, which uses hot forceps for tissue resection with specific ERBE settings, and the tip-in technique for anchoring snares, are highlighted.<br /><br />Further discussed are strategies for scarred regions, use of Band EMR, EFTR devices, and retroflexion for difficult-to-reach areas. Effective pre- and post-EMR management are essential, with follow-ups recommended to monitor recurrence, which can be as high as 20-25%. Proper tools and a comprehensive EMR toolbox are vital for the successful endoscopic removal of most lesions.<br /><br />The document emphasizes the importance of precise techniques and proper management to enhance the success of polyp removal procedures and reduce the need for surgical intervention.

Keywords

Polyp Removal

Techniques

Endoscopic Mucosal Resection

Tricky Polyps

Hot Avulsion

Non-lifting Sign

Full Thickness Resection Device

Submucosal Injection

Endoscopic Submucosal Dissection

Recurrence Management