November 30, 2017
How I remove sessile polyps
Jerome D. Waye
Professor of Medicine at the Icahn School of Medicine at Mount Sinai
New York, NY, USA
Almost all benign polyps can be removed colonoscopically.
- Use torque and dial controls to move the polyp to the 5 o’clock position.
- Polyps less than 2cm can be taken off without submucosal injection of fluid but may require piecemeal resection. Any sessile polyp over 2cm in diameter should be raised with submucosal injection of fluid to make colonoscopic polypectomy safer and easier.
- Plain saline is a good injection solution and it has been used for years. More advanced solutions may result in longer stay-time.
- Inject the part furthest away from the endoscope tip first in order to raise the polyp toward the endoscope.
- When making initial injection into the submucosa, ask the assistant to start the injection just before thrusting the needle into the mucosa. This will ensure that the solution enters the submucosal space since the fluid will expand that space immediately as the needle penetrates mucosa.
- For large polyps, inject one portion and resect that before the next injection into an adjacent area. This is preferred rather than injecting the entire polyp, lifting all the polyp and then resecting it in piecemeal fashion.
- Do not use India ink or SPOT as a solution to lift a polyp as it causes submucosal fibrosis which will make it difficult to resect recurrent / residual pieces at the subsequent colonoscopy. If injecting a marker, do it at least 2cm away from the lesion.
- Keep the snare flat in the plane of the colon wall as the polyp is captured.
- Once the open snare is over the polyp, aspirate air. As the circumference of the colon decreases, the base of the polyp which, for example, was 25% of the circumference will remain at 25% of the circumference but as the colon diameter decreases and the polyp base becomes smaller, polypoid tissue will not change its volume and actually raises up into the snare making capture easier.
- Use pure coagulation current while closing the snare. This provides maximum hemostasis. Close the snare slowly to achieve maximal hemostasis while giving electrical current during polypectomy.