Sessile serrated adenomas/polyps (SSA/Ps) are frequently found in the proximal colon, where the wall is thinner and easily damaged by diathermy during polypectomy, which also carries a risk of delayed bleeding, perforation, and post-polypectomy syndrome. SSA/Ps are often flat with subtle, irregular edges making endoscopic assessment of their extent difficult [1]. This can lead to incomplete resection and risk of post-colonoscopy cancer [2].
Currently, cold snare resection (CSR) is considered the preferred technique to resect small polyps. It is safe, time efficient, and user friendly [3]. Recently, case series have highlighted the safety and efficiency of CSR for larger adenomas [4]
[5]. In this series, we report our preliminary experience in achieving complete resection of large SSA/Ps using a cold piecemeal endoscopic mucosal resection (SCOPE) technique.
Following detection of an SSA/P, the polyp surface was assessed. The polyp was then lifted using a submucosal injection of 0.1 % hyaluronate and methylene blue, and resected using a small cold snare (9 mm, Exacto; US Endoscopy, Mentor, Ohio, USA) in a piecemeal manner ([Video 1]). A gradual increase in snare closure pressure was applied to mechanically transect each polyp piece. Each polyp was resected with a small rim of adjacent normal mucosa (1 – 2 mm) in order to achieve a complete resection margin. The polypectomy defect edges were scrutinized for any remaining polyp and trimmed using the snare, or cold avulsed with a biopsy forceps ([Fig. 1], [Video 1]).
Video 1 A 30-mm sessile serrated polyp was resected using the serrated cold piecemeal endoscopic mucosal resection (SCOPE) technique.
Fig. 1 Resection of a large sessile serrated polyp by cold piecemeal endoscopic mucosal resection (SCOPE) technique. a A 40-mm sessile serrated adenoma/polyp in the ascending colon; the edges are enhanced by chromoendoscopy. b Complete resection was achieved using the SCOPE technique. c No recurrence was observed at follow-up colonoscopy. d Normal mucosa in continuity with a serrated polyp highlights complete resection of the lesion (B1, normal mucosa; B2, serrated polyp).
The SCOPE technique was applied successfully in 10 consecutive patients with 29 large SSA/Ps. We achieved complete resection in all cases ([Table 1]). Minor oozing was noted in almost all cases; however, no hemostatic interventions were required. There were no adverse events during or after resection. Histology showed complete resection of polyps ([Fig. 1]). In one polyp (3.4 %), a small area of residual tissue was observed at the follow-up examination; this was resected using cold snaring.
Table 1
Patient and polyp characteristics.
|
Case #
|
Age, years
|
Location
|
Number of SSA/P
|
Size, mm (number of polyps)
|
Follow-up, months
|
Outcome
|
|
1
|
64
|
Ascending colon
|
1
|
30
|
12
|
No recurrence
|
|
2
|
62
|
Hepatic flexure
|
1
|
30
|
9
|
No recurrence
|
|
3
|
68
|
Ascending colon
|
1
|
30
|
7
|
5-mm residual polyp; cold snared
|
|
4
|
68
|
Ascending colon
|
1
|
20
|
7
|
No recurrence
|
|
5
|
42
|
Hepatic flexure
|
1
|
30
|
6
|
No recurrence
|
|
6
|
31
|
Cecum – transverse colon
|
7
|
10 (5), 15 (1), 20 (1)
|
12
|
No recurrence
|
|
7
|
39
|
Cecum – transverse colon
|
7
|
10 (4), 20 (3)
|
6
|
No recurrence
|
|
8
|
77
|
Ascending colon
|
2
|
12 (1), 18 (1)
|
8
|
No recurrence
|
|
9
|
34
|
Cecum – transverse colon
|
4
|
10 (2), 15 (2)
|
12
|
No recurrence
|
|
10
|
29
|
Ascending colon
|
4
|
10 (2), 15 (2)
|
7
|
No recurrence
|
SSA/P, sessile serrated adenoma/polyp.
Endoscopy_UCTN_Code_TTT_1AQ_2AD
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
