Endoscopic techniques for management of large colorectal polyps, strictures and leaks

Abstract

The implementation of screening colonoscopy with polyp removal has significantly decreased mortality rates associated with colorectal cancer (CRC), although it remains a major cause of cancer-related deaths globally. CRC typically originates from adenomatous polyps, and increased removal of these growths has led to reduced CRC incidence and mortality. Endoscopic polypectomy techniques, including hot and cold snare polypectomy, play a pivotal role in this process. While both methods are effective for small polyps (<10 mm), recent evidence favors cold snare polypectomy due to its superior safety profile and comparable complete resection rates. Large polyps (>10 mm), particularly those with advanced features, pose increased cancer risks and often require meticulous assessment and advanced endoscopic techniques, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), for resection. This chapter also provides a practical overview of endoscopic techniques for managing colonic obstructions and pericolonic fluid collections, detailing their indications, advantages, disadvantages, and complications. The goal is to improve understanding and application in clinical practice. Additionally, we provide a summary of endoscopic closure techniques that have revolutionized the management of perforations and fistulas, offering safe and effective alternatives to surgery.

Keywords: Colon polyps; Colorectal stents; Endoscopic closure devices; Endoscopic mucosal resection; Endoscopic submucosal dissection.

Image 1

Cold snare polypectomy. a, b) Steris Exacto snare; c,d) Boston Scientific Captivator cold snare with cold snare resection – courtesy BSC.

Image 2

Olympus endoloop. a) Olympus endoloop; b) Detached endoloop; c) Pedunculated polyp; d) Endoloop on stalk; e,f) Post resection (loop migrated-clips placed on stalk).

Image 3

a Left: polyp with central depression and mucosal change suggestive of deep submucosal invasion; Right: close up of central depression with irregular pit pattern. b Polyp with central depression and abnormal pit pattern suggestive of deep submucosal invasion. High definition white light image on left, FICE center and Blue light image on right.

Image 4

Submucosal injection.

Image 5

Piecemeal EMR.

Image 6

Underwater EMR.

Image 7

a Pocket method for colorectal ESD [69]. b (ESD for rectal polyp.) a) Rectal LST; b) Olympus dual knife; c) ESD circumferential incision; d) ESD submucosal dissection; e) Post ESD defect with small focal perforation; f) post suture and clip closure of ESD defect.

Image 8

ESD traction technique [69].

Image 9

EFTR. a) Periappendiceal polyp; b) Edge marking; c) FTRD/clip device on scope; d, e) S/p resection with clip in place; f, g) FTRD resected specimen (both sides).

Image 10

Hybrid APC. a) Hybrid APC after power jet injection; b) Hybrid APC after injection lift; c) Recurrent periappendiceal polyp; d) S/p partial resection/fibrosis; e) S/p Hybrid APC to fibrotic resection base.

Image 11

EMR perforation closure. a) Post injection lift polyp; b) Perforation post EMR; c) Overstitch suturing; d) S/p overstitch closure.

Image 12

Post EMR clip closure.

Image 13

Colonic balloon dilation of anastomotic stricture.

Image 14

Colonic stent placement across obstructing colon cancer.

Image 15

EUS drainage perirectal collection.

Image 16

(TTSC clip closure and OTSC). a-d) TTSC for post EMR clip closure, courtesy Boston Scientific; e-g) OTSC for closure of gastric fistula, courtesy Ovesco Endoscopy AG.

Image 17

(Overstitch device) – Courtesy Apollo Endosurgery. a) Apollo device – courtesy Apollo endosurgery; b) Post EMR focal perforation; c) Overstitch device closure; d) post Overstitch defect closure.

Image 18

X-Tack device. a) X-tack device - courtesy Apollo Endosurgery; b) Large colon polyp; c) Post EMR defect; d) s/p X-Tack defect closure.