The suction pseudopolyp technique: a novel method for the removal of small flat nonpolypoid lesions of the colon and rectum

Background and study aims: Small flat nonpolypoid lesions of the colorectum can be technically difficult to target and completely remove; techniques such as hot biopsy forceps electrocauterization are associated with serositis, delayed bleeding, and perforation. This study aimed to describe a novel technique for the removal of such lesions and demonstrate its safety and efficacy.

Patients and methods: Patients aged 18 – 80 years with flat nonpolypoid lesions (Paris-Japanese classification 0-IIa and 0-IIb, measuring less than 10 mm) identified at colonoscopy were included in this prospective study. The lesions were removed by the suction pseudopolyp technique (SPT): the lesion is aspirated into the suction channel of the colonoscope and continuous suction applied for 5 seconds whilst the colonoscope is gently retracted. On release of the suction, the resulting pseudopolyp containing the lesion and a margin of normal tissue is easily ensnared and resected. The primary outcomes were endoscopic completeness of polyp resection and complication rate.

Results: Over a 12-month period, 1231 polyps were removed during 2656 colonoscopies; 126 polyps (in 101 patients) met inclusion criteria. Complete endoscopic resection was achieved in 100 % of the polyps, without immediate or delayed complication. Of the resected lesions, 57 % had malignant potential (adenomas 47 % and sessile serrated lesions 10 %); a higher proportion of lesions removed from the right colon had malignant potential compared with those from the left colon (75 % vs. 41 %, P = 0.0066).

Conclusions: Diminutive flat lesions of the colorectum are predominantly adenomas and sessile serrated lesions. SPT is a safe, effective, and reproducible therapy for removal of these lesions.

References

• 1 Kudo S, Lambert R, Allen J I. et al . Nonpolypoid neoplastic lesions of the colorectal mucosa.  Gastrointest Endosc. 2008;  68 S3-47
• 2 Soetikno R M, Kaltenbach T, Rouse R V. et al . Prevalence of nonpolypoid (flat and depressed) colorectal neoplasms in asymptomatic and symptomatic adults.  JAMA. 2008;  299 1027-1035
• 3 Waye J D. Techniques of polypectomy: hot biopsy forceps and snare polypectomy.  Am J Gastroenterol. 1987;  82 615-618
• 4 Wadas D D, Sanowski R A. Complications of the hot biopsy forceps technique.  Gastrointest Endosc. 1988;  34 32-37
• 5 Ho S B, Krinsky M L. Quality Polyp Resection in Colonoscopy: Are We Achieving Polyp Clearance?.  Gastrointest Endosc. 2008;  67 AB79-AB80
• 6 Savides T J, See J A, Jensen D M. et al . Randomized controlled study of injury in the canine right colon from simultaneous biopsy and coagulation with different hot biopsy forceps.  Gastrointest Endosc. 1995;  42 573-578
• 7 Singh N, Harrison M, Rex D K. A survey of colonoscopic polypectomy practices among clinical gastroenterologists.  Gastrointest Endosc. 2004;  60 414-418
• 8 Winawer S J, Zauber A G, Ho M N. et al . Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup.  N Engl J Med. 1993;  329 1977-1981
• 9 Rex D K. Have we defined best colonoscopic polypectomy practice in the United States?.  Clin Gastroenterol Hepatol. 2007;  5 674-677
• 10 Levin T R, Zhao W, Conell C. et al . Complications of colonoscopy in an integrated health care delivery system.  Ann Intern Med. 2006;  145 880-886
• 11 Rembacken B J, Fujii T, Cairns A. et al . Flat and depressed colonic neoplasms: a prospective study of 1000 colonoscopies in the UK.  Lancet. 2000;  355 1211-1214
• 12 Tsuda S, Veress B, Toth E, Fork F T. Flat and depressed colorectal tumours in a southern Swedish population: a prospective chromoendoscopic and histopathological study.  Gut. 2002;  51 550-555
• 13 Hurlstone D P, Cross S S, Adam I. et al . A prospective clinicopathological and endoscopic evaluation of flat and depressed colorectal lesions in the United Kingdom.  Am J Gastroenterol. 2003;  98 2543-2549
• 14 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002.  Gastrointest Endosc. 2003;  58 (Suppl. 6) S3-S43
• 15 Higuchi T, Sugihara K, Jass J R. Demographic and pathological characteristics of serrated polyps of colorectum.  Histopathology. 2005;  47 32-40
• 16 Spring K J, Zhao Z Z, Karamatic R. et al . High prevalence of sessile serrated adenomas with BRAF mutations: a prospective study of patients undergoing colonoscopy.  Gastroenterology. 2006;  131 1400-1407
• 17 Tappero G, Gaia E, De Giuli P. et al . Cold snare excision of small colorectal polyps.  Gastrointest Endosc. 1992;  38 310-313
• 18 Van Gossum A, Cozzoli A, Adler M. et al . Colonoscopic snare polypectomy: analysis of 1485 resections comparing two types of current.  Gastrointest Endosc. 1992;  38 472-475
• 19 Parra-Blanco A, Kaminaga N, Kojima T. et al . Colonoscopic polypectomy with cutting current: is it safe?.  Gastrointest Endosc. 2000;  51 676-681
• 20 Levine D S, Haggitt R C. Normal histology of the colon.  Am J Surg Pathol. 1989;  13 966-984
• 21 Vanagunas A, Jacob P, Vakil N. Adequacy of ”hot biopsy” for the treatment of diminutive polyps: a prospective randomized trial.  Am J Gastroenterol. 1989;  84 383-385
• 22 Peluso F, Goldner F. Follow-up of hot biopsy forceps treatment of diminutive colonic polyps.  Gastrointest Endosc. 1991;  37 604-606
• 23 Efthymiou M, Chen R, Taylor A, Desmond P. Assessing the efficacy of cold biopsy forceps polypectomy for diminutive polyps.  Gastrointest Endosc. 2009;  69 AB108
• 24 Pabby A, Schoen R E, Weissfeld J L. et al . Analysis of colorectal cancer occurrence during surveillance colonoscopy in the dietary Polyp Prevention Trial.  Gastrointest Endosc. 2005;  61 385-391
• 25 Farrar W D, Sawhney M S, Nelson D B. et al . Colorectal cancers found after a complete colonoscopy.  Clin Gastroenterol Hepatol. 2006;  4 1259-1264
• 26 Goldstein N S, Watts J C, Neill J S. et al . The effect of electrothermal cautery-assisted resection of diminutive colonic polyps on histopathologic diagnosis.  Am J Clin Pathol. 2001;  115 356-361
• 27 Rex D K, Alikhan M, Cummings O, Ulbright T M. Accuracy of pathologic interpretation of colorectal polyps by general pathologists in community practice.  Gastrointest Endosc. 1999;  50 468-474
• 28 Atkin W S, Saunders B P. Surveillance guidelines after removal of colorectal adenomatous polyps.  Gut. 2002;  51 (Suppl. 5) V6-V9
• 29 Winawer S J, Zauber A G, Fletcher R H. et al . Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society.  Gastroenterology. 2006;  130 1872-1885
• 30 Mulder S A, Ouwendijk R J, van Leerdam M E. et al . A nationwide survey evaluating adherence to guidelines for follow-up after polypectomy or treatment for colorectal cancer.  J Clin Gastroenterol. 2008;  42 487-492
• 31 Levin B, Lieberman D A, McFarland B. et al . Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology.  Gastroenterology. 2008;  134 1570-1595
• 32 Hayes S J. Assessment of colorectal adenomatous polyp size measured during pathological examination highlights the importance of accuracy.  Gastrointest Endosc. 2009;  70 540-541
• 33 Laiyemo A O, Murphy G, Albert P S. et al . Postpolypectomy colonoscopy surveillance guidelines: predictive accuracy for advanced adenoma at 4 years.  Ann Intern Med. 2008;  148 419-426
• 34 Imperiale T F, Sox H C. Guidelines for surveillance intervals after polypectomy: coping with the evidence.  Ann Intern Med. 2008;  148 477-479