Today, clearing seriated polyposis syndrome or SPS on the ASGE SUTAB tip of the week. So we're going to talk today about the use of cold snare to control the polyp burden in SPS and to keep it under control and the definitions of SPS have changed. So let's review those. There are now only two types instead of three. Type one is now five seriated class lesions and that can include either a hyperplastic polyp, SSL, or TSA. I think a lot of people are not aware that a lesion that counts toward the diagnosis of SPS can be a hyperplastic polyp. Five must be proximal to the rectum and all of them have to be at least five millimeters and two of them have to be at least 10 millimeters. And then type two is now 20 seriated class lesions of any size of which at least five are proximal to the rectum. I mentioned last week that we've got a lot of patients with FAP that are referred in, but I've only seen a couple that I diagnosed myself on the basis of a diagnostic colonoscopy or something other than a referral. But that's certainly not the case with seriated polyposis syndrome, SPS. It is incredibly common. We diagnose it seems like two, three, four cases every month, either out of the referral practice or somebody that's referred with a positive Cologuard or something. It's one in every 250 screening patients have SPS. So the prevalence of it really dwarfs all the other polyp syndromes put together. We don't have a genetic test for it yet and there isn't a strong familial tendency for it. It's associated somewhat with cigarette smoking, but there are a lot of patients also that you can't really tell why or how it developed. In fact, a much higher fraction of the cases can be cleared by endoscopy compared to FAP. Basically, if there isn't cancer, almost all of them can be cleared endoscopically and followed by surveillance. And the lesions are skewed toward the proximal colon, especially the large ones in SPS. But it's important to know that half the cancers in SPS are found in the left colon. So we want to clear the left colon also. This is a woman in her 60s that I saw recently undergoing colonoscopy for a positive Cologuard. And this is her first colonoscopy and she has an obvious cancer on her ileocecal valve. So we are not going to biopsy that. We talked about earlier that when we see a cancer, the last thing that we're going to do is take the biopsy. So we saw then a serrated lesion in the right colon. This is a small serrated lesion. There was a kind of a pedunculated adenoma. Now we're in the transverse colon and we're going to start the clearing. We've already started a little bit, but we're not going to clear anything from the right colon. We'll go back later and tattoo where we want the surgery done. But I'm already, as I see the serrated lesions, I'm counting them up first to make the diagnosis. So we have seen two large serrated lesions so far, a small serrated lesion. We'll just keep counting them to make the diagnosis. But unlike FAP where we group them into the total number and the number that were 10 millimeters or larger. Now, because of the new diagnosis, we have to count the number that are 10 millimeters or larger, the number that are five to nine, and then the number that are smaller. Here's a small adenoma. Some of these patients will have both serrated lesions and adenomas. So we will continue the clearing process. But at this point I'm thinking, you know, maybe this patient has a type one serrated polyposis syndrome. But again, we tend to only see the cancers at the time that we make the initial diagnosis. During surveillance, the risk is very low. In our experience, it's zero. Across the literature from experience centers, it's quite low. Now we're back up in the right colon and there's a serrated lesion that I missed, that very flat one that was in the middle of the screen. There it is again, right in the middle of the screen. That's a very flat, large serrated lesion. That made enough for us to have the diagnosis of type one SPS. Now we're tattooing the hepatic flexure. We still haven't biopsied the cancer and then we'll go down and biopsy that cancer. But we could discuss whether or not we should just do a right hemicolectomy or extended right hemicolectomy. I didn't think the polyp burden was so great here that we couldn't just do a right hemicolectomy for this patient. All the usual staging is done. In fact, that is what happened. But we've got to count the polyps to make that initial diagnosis of SPS. Then we can use cold techniques to clear the colon. This is a different patient with type one SPS. You can see we've done one cold EMR a little bit higher in the transverse colon. We're doing a second one very nearby. There's a third one that you'll see in a second just distal to that. By definition, there have to be at least two lesions that are large that we might choose to do EMR. I usually will do cold EMR. Sometimes we'll have quite a number of these to remove. If we can't get them all in one session because of time, I'll usually bring the patient back in three or four months. And rarely we'll have to do that a couple of times to get the burden really under control. Once we've done that, we go to a year. And if we have really low polyp counts at follow-up, hardly anything over a centimeter, nothing looking very scary, we'll stretch it out to two years. I've now started in some cases going out to three years. But there's a very wide spectrum of polyp burden, so we count to make the diagnosis and we count to make sure that we're under control during follow-up for both type one and type two. So here's a patient with type two SPS, meaning they have at least 20 seriated class lesions. Again, they can be hyperplastic, at least five or above the rectum. This patient had a few polyps up in the proximal colon, but the bulk of the lesions are in the sigmoid and rectum. And I think in this first colonoscopy, we took off about 70 polyps. We're in the sigmoid right now. I tend to be aggressive and just take off everything that falls in the way of the snare. Some people only take out the lesions that are five millimeters or larger, the lesions over five millimeters in size. I tend to just clear out everything. I like to see the polyp numbers decrease with size, so we're counting as we go. I think we're at about 70 total for this patient in their first procedure. We'll bring them back in a year and we are going to hope that the numbers of lesions are going to go down. Maybe eventually we'll be able to expand the interval out to two years, probably that will be the case. But as always, you can take out polyps faster than these patients will grow them. The endocav vision is on the scope right now. We'll have a later tip about the pros and cons of using it, but a couple of places where it can get in the way. One's underneath the ileocecal valve, the other one is in the sigmoid and sometimes in SPS patients type two, I'll just take it off and remove it and it's off now. Some people have both type one and type two, but this is again, just a demonstration that the cold sneer is an incredibly safe way, free of complications, whether it's cold EMR or just cold sneering for controlling both type one and type two SPS. Thanks and see you next week on the ASGE SuTab tip of the week.

Dr. Douglas K. Rex

cold snare techniques

polyp burden

serrated polyposis syndrome

colon