Masterclass Colonoscopy: Trends and Recommendations Forward (Virtual) | February 2024-Taking on Larger Polyps in Clinical Practice, pre-referral management, Tattooing and Techniue

Taking on Larger Polyps in Clinical Practice, pre-referral management, Tattooing and Techniue

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The document discusses the management of larger colorectal polyps in clinical practice, specifically focusing on pre-referral management, tattooing, and techniques for resection. It emphasizes the importance of resecting benign polyps endoscopically instead of opting for surgery, as surgery carries higher risks, mortality, morbidity, and costs. However, there are several obstacles to endoscopic resection, including poor reimbursement for certain procedures, complications in smaller communities, resistance from patients to travel to tertiary centers, and resistance from small hospitals to lose patients.<br /><br />The document identifies areas of weakness in the management of large polyps from the perspective of a tertiary center. These include issues with tattooing, such as unnecessary tattoos, tattoos placed under lesions, and tattoos without clear designation of their relation to the lesion. Other weaknesses include insufficient assessment of lesions, inadequate photography, and inadequate triage in terms of scheduling, resection method, and time needed for the procedure.<br /><br />The document suggests using a PPD technique for tattooing, which involves approaching tangentially, lifting the needle until it's visible in the sub-Q (subcutaneous), getting a sub-Q bleb, and injecting a large amount of ink. It also recommends specific approaches for different cases, such as injecting at the distal end in 3-4 quadrants for cancers.<br /><br />Furthermore, the document highlights other management issues, such as partial resection without the intent to completely resect, biopsy of obviously benign lesions, clip closure of cold resection defects, not finding synchronous lesions, and not counting serrated lesions.<br /><br />The document discusses risk and efficiency thresholds for different resection techniques, categorizing them into very low risk with good efficiency, intermediate risk with a range of efficiency, higher risk with low efficiency, and the highest risk with poor efficiency.<br /><br />Various techniques for resection are described, including cold resection, hot resection of pedunculated polyps, underwater EMR (with or without electrocautery), conventional EMR with electrocautery, FTRD, and ESD. The document also provides guidance on when to perform cold resection, use electrocautery, and thin wire versus thick wire for resection.<br /><br />Lastly, the document suggests ways to improve efficiency, such as breaking up procedures for patients with multiple lesions and negotiating with insurers and employers.<br /><br />In conclusion, the document emphasizes the need for clinicians to determine their risk and efficiency thresholds and avoid sending patients with benign lesions to surgery when endoscopic resection is a viable option.

Keywords

colorectal polyps

pre-referral management

endoscopic resection

tattooing technique

benign polyps

complications in smaller communities

tertiary centers

PPD technique

resection techniques

efficiency thresholds