Endoscopic Management of Polyps, Polypectomy, and Combined Endoscopic and Laparoscopic Surgery
Polypectomy is fundamental to the practice of colonoscopy. Polypectomy disrupts the adenoma to carcinoma sequence, thereby reducing colorectal cancer incidence and mortality. The goals of polypectomy are the effective, safe, and efficient removal of preca
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Key Concepts • Colonoscopic polypectomy is the treatment of choice for diagnosing and removing most colon polyps. • Operator variability influences the quality of colonoscopy for both detection and resection. • Multiple questions remain about best practice techniques for colonoscopic polypectomy. • EMR of colorectal lesions is safe and effective but results in piecemeal resection that may prevent accurate histological diagnosis. Colonoscopy surveillance is required to assess for and manage local recurrence of neoplasia. • ESD is able to resect superficial lesions en bloc regardless of tumor size, location, and fibrosis. These advantages come at a cost of an increased risk of perforation, bleeding, and a longer procedure time as compared with EMR. • Combined endo-laparoscopic surgery is an adjunct to endoscopic polypectomy that may help to avoid colectomy.
Introduction It is estimated that 93,090 new cases of colon cancer will be diagnosed in the year 2015 with almost 50,000 estimated deaths due to colon cancer [1]. Although colon cancer is still the third most common cause of cancer related mortality in the USA, there has been a steady decline in the colorectal cancer incidence since the mid-1980s which is partially attributed to the introduction of colorectal cancer screening [2]. There has even been a more rapid decline in recent years (4% or greater per year from 2008 to 2011) which may be multifactorial but likely reflects the increased use of screening colonoscopy. Among adults aged 50–75 years, colonoscopy use increased from 19.1% in 2000 to 54.5% in 2013 [3]. Electronic supplementary material: The online version of this chapter (doi:10.1007/978-3-319-25970-3_5) contains supplementary material, which is available to authorized users.
Recently published data of the long-term follow-up from patients enrolled in the National Polyp Study provides evidence that colonoscopic removal of adenomatous polyps reduces colon cancer incidence and related mortality [4]. Colonoscopic polypectomy is the treatment of choice for diagnosing and removing most colon polyps. In the past decade, polypectomy technique, instrumentation, and evolution of endoscopy skills have improved polyp detection rates and the ability to remove polyps. Even so, large polyps or polyps in an anatomically difficult location can be challenging to remove endoscopically. Traditionally the most common recommendation for these patients has been to undergo a colon resection. Although the laparoscopic approach has reduced the morbidity of an abdominal operation, it still poses potential morbidities related to bowel resection. A combined approach using both laparoscopy and colonoscopy has more recently been described as an alternative to bowel resection in select patients with polyps that cannot be removed endoscopically. This chapter addresses endoscopic polypectomy—basic and advanced techniques and combined endoscopic endo-laparoscopic techniques.
Identification of Polyps Although there is little dispute about the impact of colonoscopy, there remains marked va
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