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Clin Colon Rectal Surg 2016; 29(04): 306-314
DOI: 10.1055/s-0036-1584090
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Colonic Polyps: Treatment

Emily Huang
1   Department of Surgery, University of California San Francisco, San Francisco, California
,
Ankit Sarin
2   Department of Surgery, Section of Colorectal Surgery, University of California San Francisco, San Francisco, California
› Author Affiliations
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Publication History

Publication Date:
21 November 2016 (online)

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Abstract

Colonic polyps are considered to be precursors of colon cancer based on several different molecular pathway models and should be resected with a principle of complete excisional biopsy. Several techniques are available for excisional biopsy, ranging from endoscopic techniques such as snare polypectomy, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD) to surgical colonic resection and colonic endolaparoscopic surgery (CELS). This article focuses on these modalities with contemporary recommendations for choice of modality based on the size and features of the polyp encountered upon endoscopy. In addition, the morphologically apparent risk factors for polyps harboring invasive malignancy are discussed along with implications for management. Current literature on the comparative risks and benefits of EMR, ESD, CELS, and surgical resection is reviewed, as well as recommendations regarding cancer risk and subsequent surveillance.

Keywords

adenomatous polyp - endoscopic mucosal resection - endoscopic submucosal dissection - laparoscopic colectomy - colonic endolaparoscopic surgery
 

  • References

  • 1 Kudo Se, Lambert R, Allen JI , et al. Nonpolypoid neoplastic lesions of the colorectal mucosa. Gastrointest Endosc 2008; 68 (4, Suppl): S3-S47
    CrossrefPubMedGoogle Scholar
  • 2 Inoue H, Kashida H, Kudo S , et al. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58 (6, Suppl): S3-S43
    CrossrefPubMedGoogle Scholar
  • 3 Bond JH ; Practice Parameters Committee of the American College of Gastroenterology. Polyp guideline: diagnosis, treatment, and surveillance for patients with colorectal polyps. Am J Gastroenterol 2000; 95 (11) 3053-3063
    CrossrefPubMedGoogle Scholar
  • 4 Winawer SJ, Zauber AG, Ho MN , et al; The National Polyp Study Workgroup. Prevention of colorectal cancer by colonoscopic polypectomy. N Engl J Med 1993; 329 (27) 1977-1981
    CrossrefPubMedGoogle Scholar
  • 5 Corley DA, Jensen CD, Marks AR , et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014; 370 (14) 1298-1306
    CrossrefPubMedGoogle Scholar
  • 6 Galandiuk S, Fazio VW, Jagelman DG , et al. Villous and tubulovillous adenomas of the colon and rectum. A retrospective review, 1964-1985. Am J Surg 1987; 153 (1) 41-47
    CrossrefPubMedGoogle Scholar
  • 7 Doniec JM, Löhnert MS, Schniewind B, Bokelmann F, Kremer B, Grimm H. Endoscopic removal of large colorectal polyps: prevention of unnecessary surgery?. Dis Colon Rectum 2003; 46 (3) 340-348
    CrossrefPubMedGoogle Scholar
  • 8 Gschwantler M, Kriwanek S, Langner E , et al. High-grade dysplasia and invasive carcinoma in colorectal adenomas: a multivariate analysis of the impact of adenoma and patient characteristics. Eur J Gastroenterol Hepatol 2002; 14 (2) 183-188
    CrossrefPubMedGoogle Scholar
  • 9 Seitz U, Bohnacker S, Seewald S , et al. Is endoscopic polypectomy an adequate therapy for malignant colorectal adenomas? Presentation of 114 patients and review of the literature. Dis Colon Rectum 2004; 47 (11) 1789-1796 , discussion 1796–1797
    CrossrefPubMedGoogle Scholar
  • 10 Alder AC, Hamilton EC, Anthony T, Sarosi Jr GA. Cancer risk in endoscopically unresectable colon polyps. Am J Surg 2006; 192 (5) 644-648
    CrossrefPubMedGoogle Scholar
  • 11 Oka S, Tanaka S, Kanao H, Oba S, Chayama K. Therapeutic strategy for colorectal laterally spreading tumor. Dig Endosc 2009; 21 (Suppl. 01) S43-S46
    CrossrefPubMedGoogle Scholar
  • 12 Tanaka S, Haruma K, Teixeira CR , et al. Endoscopic treatment of submucosal invasive colorectal carcinoma with special reference to risk factors for lymph node metastasis. J Gastroenterol 1995; 30 (6) 710-717
    CrossrefPubMedGoogle Scholar
  • 13 Kitajima K, Fujimori T, Fujii S , et al. Correlations between lymph node metastasis and depth of submucosal invasion in submucosal invasive colorectal carcinoma: a Japanese collaborative study. J Gastroenterol 2004; 39 (6) 534-543
    PubMedGoogle Scholar
  • 14 Uraoka T, Saito Y, Matsuda T , et al. Endoscopic indications for endoscopic mucosal resection of laterally spreading tumours in the colorectum. Gut 2006; 55 (11) 1592-1597
    CrossrefPubMedGoogle Scholar
  • 15 Kato S, Fujii T, Koba I , et al. Assessment of colorectal lesions using magnifying colonoscopy and mucosal dye spraying: can significant lesions be distinguished?. Endoscopy 2001; 33 (4) 306-310
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Kiesslich R, von Bergh M, Hahn M, Hermann G, Jung M. Chromoendoscopy with indigocarmine improves the detection of adenomatous and nonadenomatous lesions in the colon. Endoscopy 2001; 33 (12) 1001-1006
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Moss A, Bourke MJ, Williams SJ , et al. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology 2011; 140 (7) 1909-1918
    CrossrefPubMedGoogle Scholar
  • 18 Boix J, Lorenzo-Zúñiga V, Moreno de Vega V , et al. Endoscopic removal of large sessile colorectal adenomas: is it safe and effective?. Dig Dis Sci 2007; 52 (3) 840-844
    CrossrefPubMedGoogle Scholar
  • 19 Brooker JC, Saunders BP, Shah SG, Williams CB. Endoscopic resection of large sessile colonic polyps by specialist and non-specialist endoscopists. Br J Surg 2002; 89 (8) 1020-1024
    CrossrefPubMedGoogle Scholar
  • 20 Waye JD. How big is too big?. Gastrointest Endosc 1996; 43 (3) 256-257
    CrossrefPubMedGoogle Scholar
  • 21 Binmoeller KF, Bohnacker S, Seifert H, Thonke F, Valdeyar H, Soehendra N. Endoscopic snare excision of “giant” colorectal polyps. Gastrointest Endosc 1996; 43 (3) 183-188
    CrossrefPubMedGoogle Scholar
  • 22 Seo GJ, Sohn DK, Han KS , et al. Recurrence after endoscopic piecemeal mucosal resection for large sessile colorectal polyps. World J Gastroenterol 2010; 16 (22) 2806-2811
    CrossrefPubMedGoogle Scholar
  • 23 Conio M, Repici A, Demarquay JF, Blanchi S, Dumas R, Filiberti R. EMR of large sessile colorectal polyps. Gastrointest Endosc 2004; 60 (2) 234-241
    CrossrefPubMedGoogle Scholar
  • 24 Zlatanic J, Waye JD, Kim PS, Baiocco PJ, Gleim GW. Large sessile colonic adenomas: use of argon plasma coagulator to supplement piecemeal snare polypectomy. Gastrointest Endosc 1999; 49 (6) 731-735
    CrossrefPubMedGoogle Scholar
  • 25 Brooker JC, Saunders BP, Shah SG, Thapar CJ, Suzuki N, Williams CB. Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations. Gastrointest Endosc 2002; 55 (3) 371-375
    CrossrefPubMedGoogle Scholar
  • 26 Consolo P, Luigiano C, Strangio G , et al. Efficacy, risk factors and complications of endoscopic polypectomy: ten year experience at a single center. World J Gastroenterol 2008; 14 (15) 2364-2369
    CrossrefPubMedGoogle Scholar
  • 27 Tanaka S, Haruma K, Tanimoto T , et al. Ki-67 and transforming growth factor alpha (TGF-a) expression in colorectal recurrent tumors after endoscopic resection. Recent Adv Gastroenterol Carcinogen 1996; 1: 1079-1083
    PubMedGoogle Scholar
  • 28 Netzer P, Forster C, Biral R , et al. Risk factor assessment of endoscopically removed malignant colorectal polyps. Gut 1998; 43 (5) 669-674
    CrossrefPubMedGoogle Scholar
  • 29 Fujihara S, Mori H, Kobara H , et al. Current innovations in endoscopic therapy for the management of colorectal cancer: from endoscopic submucosal dissection to endoscopic full-thickness resection. Biomed Res Int 2014; 2014: 925058
    PubMedGoogle Scholar
  • 30 Tanaka S, Oka S, Kaneko I , et al. Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization. Gastrointest Endosc 2007; 66 (1) 100-107
    CrossrefPubMedGoogle Scholar
  • 31 Saito Y, Uraoka T, Matsuda T , et al. Endoscopic treatment of large superficial colorectal tumors: a case series of 200 endoscopic submucosal dissections (with video). Gastrointest Endosc 2007; 66 (5) 966-973
    CrossrefPubMedGoogle Scholar
  • 32 Saito Y, Fukuzawa M, Matsuda T , et al. Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection. Surg Endosc 2010; 24 (2) 343-352
    CrossrefPubMedGoogle Scholar
  • 33 Saito Y, Uraoka T, Yamaguchi Y , et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc 2010; 72 (6) 1217-1225
    CrossrefPubMedGoogle Scholar
  • 34 Yoshida N, Naito Y, Kugai M , et al. Efficient hemostatic method for endoscopic submucosal dissection of colorectal tumors. World J Gastroenterol 2010; 16 (33) 4180-4186
    CrossrefPubMedGoogle Scholar
  • 35 Repici A, Hassan C, De Paula Pessoa D , et al. Efficacy and safety of endoscopic submucosal dissection for colorectal neoplasia: a systematic review. Endoscopy 2012; 44 (2) 137-150
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 Hurlstone DP, Atkinson R, Sanders DS, Thomson M, Cross SS, Brown S. Achieving R0 resection in the colorectum using endoscopic submucosal dissection. Br J Surg 2007; 94 (12) 1536-1542
    CrossrefPubMedGoogle Scholar
  • 37 Tanaka S, Tamegai Y, Tsuda S, Saito Y, Yahagi N, Yamano HO. Multicenter questionnaire survey on the current situation of colorectal endoscopic submucosal dissection in Japan. Dig Endosc 2010; 22 (Suppl. 01) S2-S8
    CrossrefPubMedGoogle Scholar
  • 38 Probst A, Golger D, Anthuber M, Märkl B, Messmann H. Endoscopic submucosal dissection in large sessile lesions of the rectosigmoid: learning curve in a European center. Endoscopy 2012; 44 (7) 660-667
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Kunihiro M, Tanaka S, Haruma K , et al. Electrocautery snare resection stimulates cellular proliferation of residual colorectal tumor: an increasing gene expression related to tumor growth. Dis Colon Rectum 2000; 43 (8) 1107-1115
    CrossrefPubMedGoogle Scholar
  • 40 Bertelson NL, Kalkbrenner KA, Merchea A , et al. Colectomy for endoscopically unresectable polyps: how often is it cancer?. Dis Colon Rectum 2012; 55 (11) 1111-1116
    CrossrefPubMedGoogle Scholar
  • 41 Pokala N, Delaney CP, Kiran RP, Brady K, Senagore AJ. Outcome of laparoscopic colectomy for polyps not suitable for endoscopic resection. Surg Endosc 2007; 21 (3) 400-403
    CrossrefPubMedGoogle Scholar
  • 42 Loungnarath R, Mutch MG, Birnbaum EH, Read TE, Fleshman JW. Laparoscopic colectomy using cancer principles is appropriate for colonoscopically unresectable adenomas of the colon. Dis Colon Rectum 2010; 53 (7) 1017-1022
    CrossrefPubMedGoogle Scholar
  • 43 Kyzer S, Bégin LR, Gordon PH, Mitmaker B. The care of patients with colorectal polyps that contain invasive adenocarcinoma. Endoscopic polypectomy or colectomy?. Cancer 1992; 70 (8) 2044-2050
    CrossrefPubMedGoogle Scholar
  • 44 Kashida H, Kudo SE. Early colorectal cancer: concept, diagnosis, and management. Int J Clin Oncol 2006; 11 (1) 1-8
    CrossrefPubMedGoogle Scholar
  • 45 Guillou PJ, Quirke P, Thorpe H , et al; MRC CLASICC trial group. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 2005; 365 (9472) 1718-1726
    CrossrefPubMedGoogle Scholar
  • 46 Fleshman J, Sargent DJ, Green E , et al; Clinical Outcomes of Surgical Therapy Study Group. Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial. Ann Surg 2007; 246 (4) 655-662 , discussion 662–664
    CrossrefPubMedGoogle Scholar
  • 47 Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004; 350 (20) 2050-2059
    CrossrefPubMedGoogle Scholar
  • 48 Gustafsson UO, Scott MJ, Schwenk W , et al; Enhanced Recovery After Surgery Society. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012; 31 (6) 783-800
    CrossrefPubMedGoogle Scholar
  • 49 Stephen AE, Berger DL. Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection. Surgery 2003; 133 (3) 277-282
    CrossrefPubMedGoogle Scholar
  • 50 Basse L, Thorbøl JE, Løssl K, Kehlet H. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum 2004; 47 (3) 271-277 , discussion 277–278
    CrossrefPubMedGoogle Scholar
  • 51 Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J ; Enhanced Recovery After Surgery Study Group. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 2011; 146 (5) 571-577
    CrossrefPubMedGoogle Scholar
  • 52 Yan J, Trencheva K, Lee SW, Sonoda T, Shukla P, Milsom JW. Treatment for right colon polyps not removable using standard colonoscopy: combined laparoscopic-colonoscopic approach. Dis Colon Rectum 2011; 54 (6) 753-758
    CrossrefPubMedGoogle Scholar
  • 53 Nakajima K, Sharma SK, Lee SW, Milsom JW. Avoiding colorectal resection for polyps: is CELS the best method?. Surg Endosc 2015; 30 (3) 807-818
    PubMedGoogle Scholar
  • 54 Lee SW, Garrett KA, Shin JH, Trencheva K, Sonoda T, Milsom JW. Dynamic article: long-term outcomes of patients undergoing combined endolaparoscopic surgery for benign colon polyps. Dis Colon Rectum 2013; 56 (7) 869-873
    CrossrefPubMedGoogle Scholar