Table 3.

Technical Tips for the Removal of larger SSA/Ps by Endoscopic Mucosal Resection

Carefully inspect the lesion for features of dysplasia and peripheral extent. Use of high definition scopes with or without chromoendoscopy or NBI may assist. Dye based submucosal lift solution for EMR aids in delineating the lesion’s peripheral extent.107 Ensure snare captures a peripheral rim of 1 to 2 mm normal mucosal tissue around the polyp. Utilize EMR rather than hot snare polypectomy for SSA/Ps 10 to 20 mm as this has higher rates of complete polyp resection. Piecemeal cold snare polypectomy is an alternative technique. Firmly anchor the snare catheter in normal tissue 1 to 2 mm front of the polyp, and allow the polyp to fall into the open snare by deflating the lumen. With further deflation, close the snare to capture the polyp, but do not close completely. At this point, we prefer to take control of the snare from the assistant, closing to within 1cm. Mobility of the captured tissue relative to the adjacent bowel wall is assessed, followed by tissue resection with electrocautery (EndoCut Q, effect 3, cut duration 1, cut interval 6; VIO 300D; Erbe). Carefully assess the resection margins to assess for residual polyp. Defect expansion with water jet irrigation may assist inspection. Residual polyp can be subtle and further resections can be performed to remove suspect tissue. Recurrence after EMR can be reduced by ablating the resection margins with snare tip soft coagulation (effect 4, 80W) by a light touch technique. Referral to a center with expertise in advanced polypectomies is recommended if there is insufficient local expertise in EMR.117,118

SSA/Ps, sessile serrated adenoma/polyps; NBI, narrow band imaging; EMR, endoscopic mucosal resection.