Endoscopic Polypectomy

Overview

In affluent nations, colorectal cancer is one of the most frequent malignancies. The adenoma to carcinoma sequence describes how most colorectal malignancies develop from colorectal adenomatous polyps. Colorectal adenomas can be detected and removed early to avoid the development of colorectal cancer. The great majority of these polyps are endoscopically removed. Endoscopic resection methods have advanced, allowing for more indications for endoscopic polypectomy, which can treat huge polyps, scarred lesions, and early malignancies.

 

What are polyps?

A polyp is an abnormal lump of tissue that has formed on the body's mucous membrane. Polyps form as a result of genetic abnormalities within cells that cause abnormal growth. Many polyps can become cancerous over time, thus it is critical to diagnose and remove them. This is especially true in the colon.

are most typically found in the colon, stomach, uterus, urinary bladder, and nasal canals, although they can appear on the cells that border the majority of internal organs. Because they seldom produce symptoms, they might go unnoticed until a diagnostic screening check, such as a colonoscopy, is performed.

Polyps are most frequent in the colon and rectum, although they can also be seen in the esophagus, stomach, small intestine, gall bladder, bile ducts, and pancreas. Colon polyps are more common in those over the age of 50, those with a family history of polyps, smokers, sedentary people, and those who are overweight. African-Americans are more likely to have polyps. Certain disorders, such as ulcerative colitis, predispose to colon polyps, while several uncommon hereditary conditions predispose to small intestine and stomach polyps.

 

What is Polypectomy?

The surgical excision of a polyp is known as a polypectomy. Colon polyps can be removed by open abdominal surgery, although it is most often done via a colonoscopy. The endoscopist may use forceps to remove a little polyp or a snare that burns through the polyp's base to remove a bigger polyp.

Polyps can be malignant or noncancerous (noncancerous). They're normally harmless, but your doctor won't know for sure until they remove it. Some polyps are "precancerous," which means they aren't cancerous right now but might develop into cancer later.

 

Background

In the early 1970s, endoscopic polypectomy was offered as a revolutionary procedure. The National Polyp Study proved the usefulness of this approach in avoiding the development of colorectal cancer. Endoscopic excision of colonic polyps has advanced at a rapid pace during the last several decades. As a result, the use of endoscopy in the therapy of extremely big polyps and polyps with more invasive disease has expanded, avoiding surgery.

Colonoscopic polypectomy is the initial and standard therapy for colon rectal polyps and, as a result, colorectal cancer prevention. When conducted by skilled hands utilizing a careful method and correctly functioning equipment, it is a safe technique, and problems should be rare.

Some characteristics, such as the form (pedunculated or sessile) and size of the polyp, its location, and other factors related to the patient's comorbidities (coagulation disorders or medication intake), as well as the method utilized, might increase the risk of problems.

The most common consequences following polypectomy are bleeding (ranging from 0.3% to 6.1%) and discomfort caused by either excessive gas collection or parietal injury and perforation from current application. These problems frequently occur after big polyps polypectomies. Several authors have observed difficulties with the endoscopic removal of big polyps, with "large" being defined as equal to or more than 20 mm in the majority of these investigations.

Large polyps pose a special difficulty for the endoscopist since they are frequently associated with significant risks of bleeding, perforation (0%-1.3%), and poor polypectomy. The surgical excision of big polyps, which requires hospitalization and anesthesia, is an option to endoscopic treatment. Furthermore, the dangers of surgery are substantial, particularly in older individuals with concomitant conditions. Furthermore, the increased rates of death (2%-4%) and morbidity (10%) observed for surgery compared to endoscopic polypectomy cannot be neglected.

 

Advances in Polyp Assessment

Good evaluation underpins the success of endoscopic polyp removal. As a result, prior to excision, a polyp's type (benign versus malignant) and degree of intricacy must be determined. The basic size, morphology, location, and access scoring method may be used to identify complicated polyps. Level 1 and Level 2 polyps are regarded less complicated under this approach, and hence all independent colonoscopists should be able to resect these polyps as part of a normal colonoscopy.

Level 3 polyps are complicated and should be removed by a skilled colonoscopist in a specific session. Finally, Level 4 polyps are regarded extremely complicated and have historically been treated surgically. However, professionals at high-volume centers may now successfully resect such polyps.

Is a polypectomy a minor surgery?

Yes. A polypectomy is a minor surgical surgery. The majority of polypectomies do not even involve an incision into your body to access the polyp. Internally, they may normally be handled with medical equipment passed through natural holes in your body.

When polyps are identified during a colonoscopy or endoscopic exam, they are often removed. A lighted scope is sent down your throat or via your anus and into your organs during these inspections. Surgeons can use the scope to do small surgeries.

Your surgeon may need to approach a polyp via your belly in more challenging circumstances. They can accomplish this using minimally invasive surgery techniques such as laparoscopy. This entails inserting a scope through one small "keyhole incision" and doing surgery through another. 

 

What happens before a polypectomy?

Preparation: 

Many polypectomies do not need any particular preparation. However, if you're undergoing a colonoscopy to check for or remove colon polyps, your bowels must be clean. Your healthcare professional will suggest a bowel prep formula to assist clean up your intestines before the surgery. Each recipe comes with its own set of instructions. Most require a particular diet in the days preceding up to the surgery. The colonoscopy preparation might take up to 24 hours.

 

Medication:

In advance, the anesthesiologist will go through your pain medication options with you. To prepare you for the surgery, they will provide your sedative or anaesthetic through an IV in your vein. You may also need to take oral drugs before or after the procedure. Certain drugs may be prohibited by your healthcare practitioner on the day of your treatment.

 

What happens during a polypectomy?

An endoscopic method is used for a simple polypectomy. This is accomplished with an endoscope, which is a long, flexible tube with a lit camera attached. Different versions are created to access various bodily channels. For example, a colonoscopy examines your big intestine with a colonoscope. Your healthcare practitioner will send the endoscope into your anus to reach the relevant organ. Images will be projected onto a screen via the camera. These photos will be used by your healthcare practitioner to direct the scope to the site of your polyp. They may use carbon dioxide gas to expand your organ so they can view it better via the endoscope.

To remove the polyp, your healthcare professional will put tiny devices through the scope. They may use surgical forceps or a wire snare to remove the polyp. To assist immobilize the polyp, the instruments are either chilled or heated. Different equipment and approaches are more effective for eliminating certain types of polyps in various areas. They'll take it out in the same way they put it in.

A simple polypectomy removes the polyp from the base or stalk without causing any damage to the surrounding tissue. As a result, a little quantity of polyp tissue may be left behind. Your doctor will burn it away with an electrocautery instrument, which is a gadget that uses an electric current. This helps to guarantee that the polyp does not reappear, as well as cauterize (close) the incision and keep it from bleeding.

 

What happens after a polypectomy?

You should be able to return home shortly, though you may need someone to drive you. Under the influence of anesthetic, you may still be wobbly or disoriented. You may have residual gas trapped inside you from the surgery, which may cause slight discomfort until it passes. If your digestive system was harmed, you may need to be patient with it over the following few days.

Your polyps will be sent to a lab for analysis by your healthcare professional. The findings will be available in one to two weeks. The majority of polyps are harmless. If they discover indications of malignancy, they will arrange more tests and treatments. Even if your polyp is benign, they will want to test you again periodically to check if any new polyps emerge.

Recovery time is generally only a few days. For a day or two, you may be using prescription or over-the-counter pain relievers. Depending on where your polyp was removed, you may notice some minor bleeding in your feces or urine. This is normal, but if you experience severe or persistent bleeding, visit your healthcare professional.

 

What is postpolypectomy coagulation syndrome?

Postpolypectomy coagulation syndrome (also known as postpolypectomy syndrome or transmural burn syndrome) is an uncommon complication that can occur following a polypectomy. It occurs when the electrocautery equipment used to remove the polyp stump burns into the surrounding tissue. Abdominal discomfort, fever, and leukocytosis are possible symptoms (high white blood cell count, a sign that your immune system has been activated).

The symptoms of postpolypectomy coagulation syndrome (PPCS) are similar to those of a more serious tissue puncture or rupture. Surgery would be required to fix a tear. However, postpolypectomy syndrome is a less serious illness that may be treated with medicine and dissipates within a few days. Symptoms normally develop within 12 hours of your surgery, although it might take several days. If you have any symptoms, please notify your healthcare professional.

 

What if I need a more complex type of polyp resection?

For a variety of reasons, some polyps may be difficult to remove with a basic polypectomy. They may be too flat or too large to grab with forceps or a snare, or they may be in a region that is difficult to view properly or difficult to reach without injuring the surrounding tissue. When there is evidence of invasive malignancy, a new method is required to remove the polyp and all malignant tissue with it.

Some alternative approaches include:

• Laparoscopic surgery: If your surgeon needs to cut into your belly to access a polyp, they will use minimally invasive surgery techniques. Laparoscopic surgery is performed through a few tiny half-inch keyhole incisions. One holds the laparoscope, while the other holds the surgical equipment.
• Endoscopic mucosal resection: Endoscopic mucosal resection (EMR) is comparable to a basic polypectomy in that the polyp is captured with a snare. The distinction is that it cuts beneath the polyp into the mucosa. A saline solution is injected into the mucosa beneath the polyp to raise it for easy access.
• Endoscopic submucosal dissection: Endoscopic submucosal dissection (ESD) may be required to remove polyps that are very big or seem to be malignant. An electrosurgical cutting instrument is used in ESD to cut into the deeper submucosa layer beneath the polyp. Larger polyps can be removed in one piece without leaving any tissue behind.

 

Can you remove all polyps during endoscopy?

During an endoscopy, your doctor carefully examines all polyps for signs of precancerous or cancerous development. Some polyps are harmless, so we leave them alone. The size and position of most precancerous colon polyps (> 95 %, depending on the operator's competence) allow for real-time endoscopic excision. The remainder may need surgery or another method.

Polyps are uncommon in the small intestine; we can resect many of them using endoscopic procedures, but many others require laparoscopic surgery. Most polyps in the stomach are harmless; when necessary, we can usually remove stomach polyps endoscopically.

 

What are the risks of polypectomy?

Polypectomy is usually considered safe. The biggest dangers include bleeding from vessels transected during the surgery; we reduce this risk with cautery and the installation of iron clips over any vessels that are transected. Another significant danger is penetration of the colon wall, which is extremely thin (a couple of millimeters in thickness). To reduce this risk, we employ a number of tactics and procedures. Overall, the risk of complications is determined by the size of the polyp, the doctor's experience, and your overall health. For example, using blood thinners raises your chance of post-procedure bleeding.

 

Surgery vs. Polypectomy

Historically, complex colon polyps required surgery. However, competent GI specialists may now remove them by colonoscopy. Both techniques have comparable recurrence rates, but other considerations impact the choice.

Polypectomy can be performed with a colonoscope (a thin, flexible tube) by putting fluid under the polyp to lift it and then removing it with a snare. To prevent bleeding, a heat current in the snare cauterizes tissue at the wound. Polypectomy patients have little discomfort with the use of a sedative.

Surgery, on the other hand, includes making small incisions in the belly to insert small instruments and a camera laparoscopically into the abdomen, which is enlarged with carbon dioxide. In other circumstances, open surgery is necessary, which requires a bigger incision into the abdominal wall.

Unlike a polypectomy, a portion of the colon is removed to guarantee that the polyp and any associated malignancy are completely eradicated. For the duration of the procedure, which might last several hours, all patients are sedated.

 

Varying recoveries

A polypectomy is an outpatient treatment that takes 30 to 60 minutes and allows patients to go home the same day. They should be able to resume their usual schedule the next day. Patients who have a big polyp removed endoscopically normally require a follow-up operation in three to six months to ensure there is no residual tissue. Those who have surgery typically stay in the hospital for three days, although this can treble if complications emerge. Another potential stumbling block: postoperative ileus, defined as a normal response to the unnatural insertion of instruments into the abdomen and anesthesia, resulting in paralysis of the gut that might take several days to cure.

 

Conclusion

Polyps are removed because some of them may grow into colon cancer, and colon cancer occurs in polyp areas with a few exceptions. The only way to be positive that cancer isn't present is to remove and analyze the polyp in the lab. The polyp is removed using a special endoscope that is passed through the gut lumen.