From the Guidelines
The best and safest treatment approach for this patient is cold EMR of the large lesions, followed by cold snare polypectomy of the remaining lesions. This approach is based on the most recent and highest quality evidence from the US Multi-Society Task Force on Colorectal Cancer 1.
Key Considerations
- For small lesions (less than 5mm), cold snare polypectomy is preferred due to its high complete resection rates and safety profile 1.
- For medium-sized lesions (5-20mm), cold or hot snare polypectomy with or without submucosal injection can be used, with EMR considered for non-polypoid and serrated lesions in this size range 1.
- For larger lesions (>20mm), EMR is recommended as the preferred treatment method to provide complete resection and minimize morbidity, mortality, and cost associated with surgical treatment 1.
Treatment Approach
- The patient has approximately 30 lesions, with 7-10 larger than 1 cm, and most appearing serrated by endoscopic criteria.
- Given the size and characteristics of the lesions, cold EMR of the large lesions, followed by cold snare polypectomy of the remaining lesions, is the most appropriate approach.
- This approach allows for complete removal of all lesions, minimizing the risk of incomplete resection or recurrence, and reducing the risk of progression to colorectal cancer.
Additional Recommendations
- An endoscopist experienced in advanced polypectomy should manage the patient's care 1.
- The use of a contrast agent, such as indigo carmine or methylene blue, in the submucosal injection solution can facilitate recognition of the submucosa from the mucosa and muscularis propria layers 1.
- Prophylactic closure of resection defects ≥20 mm in size in the right colon should be considered when feasible 1.
From the Research
Treatment Approaches for Colorectal Lesions
The patient in question has approximately 30 lesions identified proximal to the splenic flexure, with 7-10 larger than 1 cm and most appearing serrated by endoscopic criteria. Considering the size and number of lesions, the treatment approach should prioritize both efficacy and safety.
Options for Treatment
- Hot EMR of the large lesions, followed by hot snare polypectomy of the remaining lesions: This approach is a common method for removing colorectal polyps but may carry a higher risk of bleeding and other complications compared to cold techniques 2, 3.
- Surgical resection: This is typically reserved for cases where endoscopic removal is not feasible or has failed, due to its higher risk profile and invasiveness.
- Argon plasma coagulation of all lesions: This method is less commonly used for the removal of colorectal polyps and may not be as effective for larger lesions.
- Cold EMR of the large lesions, followed by cold snare polypectomy of the remaining lesions: Cold techniques have been shown to have a lower risk of delayed bleeding and may be suitable for the removal of non-cancerous polyps up to 9 mm or even larger sessile serrated polyps 4, 5, 6.
Evidence Supporting Cold EMR and Snare Polypectomy
Studies have demonstrated the safety and efficacy of cold EMR for large sessile serrated polyps 5. Additionally, comparative meta-analyses have found cold snare polypectomy to be a safe, efficient, and effective technique comparable to EMR, with a significantly lower delayed bleeding rate 6. The choice between cold and hot techniques should be based on individual patient and polyp characteristics, considering factors such as polyp size, location, and the patient's risk profile for bleeding or other complications.
Considerations for the Patient's Case
Given the patient's specific situation, with multiple lesions including some larger than 1 cm and most appearing serrated, cold EMR followed by cold snare polypectomy could be considered a viable and safe approach, minimizing the risk of complications such as delayed bleeding 4, 5, 6. However, the decision should be made on a case-by-case basis, taking into account the expertise of the endoscopist and the specific characteristics of the lesions 2, 3.