Endoscopic Mucosal Resection for Curative Excision of Large Colon Polyps

Karukurichi S Venkatesh, MD, Sandra Yee, MD. Tri-City Colo-Rectal Surgery, Ltd.

Out of 122 patients with histologically proven benign polyps of the colon, two centimeters or over, 108 patients were deemed suitable for curative endoscopic excision, after careful selection process, over a 40 month period. Eight patients underwent lap-assisted colonoscopic excision of polyps and were excluded from the study. The polyps were four centimeters or larger in 40 patients. The age range of this group of 100 patients is 25 to 83 years. The polyps were located in the left colon in 64 percent of the patients. Polyps of the rectum were excluded from this study.

Technique: In 78 percent of the patients, the procedure was performed in the operating suite with IV sedation, using propofol given by anesthesiologist. The rest were performed in an ambulatory surgical center. Both small and large snares were used in all patients. The polyp excision was achieved with submucosal lift using saline and overlapping multiple passages of the snare. Piecemeal excision with snare was used for larger polyps. The snare was held tight at the polyp base for one to two minutes, depending on the size of the polyp segment that was caught. Wide fulguration of the surrounding mucosa was then performed. Submucosal injection of epinephrine was used around the polyp base at the end of the procedure. All patients were discharged after two hour stay in the recovery room. No immediate or delayed perforations occurred. One patient had immediate bleeding following excision, controlled with hemoclip, requiring the lone admission to the hospital overnight. In four patients we were unable to excise the polyp curatively. One patient age 83 had opted not to do anything further. One patient had another attempt at endoscopic excision at another institution, which also failed, resulting in laparoscopic resection. The other two patients underwent laparoscopic resection.

Results: Of patients with successful excision, three patients required colon resection due to invasive carcinoma extending to the margin of resection. Five patients had superficial invasive cancer, 5-10% of the volume of the polyp without submucosal involvement. Ten patients had high grade dysplasia. All patients were followed with another colonoscopy at three months and at one year. Three patients had recurrences at excision site requiring successful re-excision and fulguration at three months.

Conclusion: Large polypoid lesions of the colon can be successfully curatively excised using endoscopic mucosal resection.

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