Endoscopic management of residual polyp from previously manipulated colon lesions. Authors Shifa Umar, Dennis Chen, Amrita Sethi, Uzma Siddiqui. Keywords. Disclosures. Scar lesions can often be identified by a non-lifting sign. Typically during endoscopic resection, a solution is injected into the submucosa to provide a cushion or separation from the muscle layer and allow for safe resection. If there is substantial fibrosis in the submucosa, this injection fails to create any separation of the submucosal layer and results in a non-lifting sign. While typically thought of as a sign of invasive cancer, this can also be seen in lesions with a history of prior manipulation, including aggressive biopsies, incomplete resection attempt, and tattoo injection into the lesion. A descending colon polyp with prior resection attempt and residual adenoma was referred to our center. For EMR, a distal attachment cap was utilized to help scope tip position and also help suction tissue into the cap. Initially, submucosal injection is performed and then underwater EMR is performed to resect the tissue that does lift to try and localize the scarred area. Finally, a small fibrotic area is left and cannot be captured by the snare. Therefore, heart avulsion technique is performed. Heart biopsy forceps are used to grasp tissue and avulse it using a combination of mechanical traction with simultaneous application of short bursts of cutting current to cut through the adherent tissue. In a retrospective study of 223 patients, 63 patients underwent piecemeal EMR with APC for ablation of visible residual tissue and 42 patients underwent piecemeal EMR with avulsion of visible residual tissue. Recurrence rate in the APC group was 59% versus only 10% in the avulsion group. Band EMR. A common referral we encounter in advanced practice is dealing with rectal polyps which have been removed previously with positive marginal pathology. We routinely perform band ligation EMR of the rectal scar to ensure complete endoscopic resection. The band ligation technique of EMR uses the existing technology of variceal band ligation to suction a flat lesion into the cap and deploy a band over this to create a pseudopolyp before resection with an electrocautery snare. A few caveats to this technique. It is off-label use since these band resection kits are only FDA approved for use in upper GI tract. We recommend avoiding this technique outside the rectum due to thinner colon wall and risk for perforation. If in-block resection is desired, lesion should be less than 15 mm in size due to the cap and band size limitation. In a study performed at our center for follow-up in 37 patients with rectal neuroendocrine tumor, the scar site was evaluated and resected using a band EMR and residual net in resection specimen was found in 38% of the cases. This highlights the need to ensure complete resection of residual tissue, submucosal resection is necessary. Endoscopic full thickness resection. EFTR with an FDA approved full thickness resection device has been described as an effective and safe tool for resection of small, less than 2 cm non-lifting scarred lesions. 50-year-old female with Lynch syndrome and colon cancer status post-subtotal colectomy was referred to us after resection of a 15 mm rectosigmoid polyp with path consistent with invasive moderately differentiated adenocarcinoma with a positive margin. Patient declined further surgery. Endoscopic full thickness resection was performed using the full thickness resection device. This involved bringing the lesion into the cap with a grasping device to ensure full thickness tissue capture, deploying an over-the-scope clip, and closing the snare to resect the lesion. Full thickness resection was achieved. In a multi-center analysis of 104 patients with non-lifting adenomas, EFTR was performed. Target lesion was reached in 100% of the cases with an R0 resection care of 77%. At 3-month follow-up in 117 patients, residual neoplasia was noted in 18 of these patients only. Powered endoscopic tissue resection device. For a previously incompletely resected transverse colon polyp which did not lift with submucosal injection, the powered endoscopic tissue resection device was used. The lesion boundary is marked with soft coagulation snare-tip cautery. The lesion is then injected with a solution of saline, blue dye, and dilute epi. The use of epinephrine before using this resection device is for the purpose of limiting mucosal oozing or bleeding during the procedure. The catheter is passed through the instrument channel. Endoscopic tissue resection is performed, starting from one edge of the lesion and repeated in a stepwise fashion until the entire lesion is resected. The resected tissue is then suctioned through the catheter and collected into a tissue filter located on the system console. It needs to be noted, if there's significant torque or tension on the scope, it may impair rotation of the cutting blade. And if the suction setting is too high, there's an increased risk of perforation due to full thickness tissue capture. With this technique, only small pieces of tissue are obtained without any orientation. Hence, it cannot be used for potentially malignant lesions due to inability to assess margins. In a four-center retrospective view of 45 lesions where patient underwent powered endoscopic debridement, initial technical success was 98% with a median procedure time of 58 minutes. Complications were noted for intraprocedural bleeding up to 29% with delayed bleeding up to 6% and no perforations. Dissection enables scaffold-assisted resection, T-scot. Our group has developed a unique cutting technique utilizing ESD skills and cutting knives to dissect out tissue surrounding scarred residual polyp tissue to provide a mold or scaffold in which to place a snare and more easily capture the scarred tissue, as shown here. In a four-year experience from our center, 54 patients underwent T-scar with a 98% success rate Adverse events included delayed bleeding episodes only in two patients and one small perforation managed endoscopically with Hemoclip. Scarred benign lesions can be encountered in previously manipulated colon polyps and present a technical challenge. Fortunately, there is an expanding air of tools and techniques to manage these tough lesions as described today.

endoscopic management techniques

residual polyps

colon

scarred tissue

complete resection