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, which recommends endoscopic resection as the primary approach for removing colorectal lesions, with specific techniques chosen based on lesion size and morphology 1.
Key Considerations
- For small lesions (<5mm), cold snare polypectomy is preferred due to its high complete resection rates and safety profile 1.
- For larger lesions (5-20mm), cold or hot snare polypectomy (with or without submucosal injection) is suggested, with EMR considered for non-polypoid and serrated lesions in the 10- to 19-mm size range 1.
- For lesions >20mm, EMR is recommended as the preferred treatment method, with an experienced endoscopist managing the procedure to minimize the risk of incomplete resection or recurrence 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, and a viscous injection solution can help remove the lesion in fewer pieces and less procedure time compared to normal saline 1.
Surveillance and Follow-Up
- Surveillance colonoscopy should follow at intervals determined by the number, size, and histology of removed lesions, typically 1-3 years for high-risk findings and 3-5 years for low-risk findings.
- For patients with numerous lesions (>10), genetic testing should be considered to rule out polyposis syndromes.
- In cases where endoscopic management isn't feasible due to size, location, or suspected invasive cancer, surgical resection becomes necessary.
Quality of Polypectomy
- The majority of benign colorectal lesions can be safely and effectively removed using endoscopic techniques, and endoscopy should be the first-line management of benign colorectal lesions.
- Endoscopists should engage in a local quality-assurance program, including measuring and reporting of post-polypectomy adverse events, and consider using polypectomy competency assessment tools in endoscopic training programs and practice improvement programs 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 being larger than 1 cm and most appearing serrated by endoscopic criteria. Considering the size and type of lesions, the best treatment approach should prioritize both efficacy and safety.
Cold Snare Polypectomy (CSP) vs. Hot Snare Polypectomy (HSP)
- CSP is recommended for diminutive polyps (size ≤ 5 mm) due to its high rates of complete resection, adequate tissue sampling, and low complication rates 2.
- For sessile polyps 6 - 9 mm in size, CSP is suggested because of its superior safety profile, although evidence comparing efficacy with HSP is lacking 2.
- HSP (with or without submucosal injection) is suggested for removal of sessile polyps 10 - 19 mm in size, considering the potential risk of deep thermal injury 2.
- Recent studies suggest that CSP can be safely implemented for lesions ≥ 1 cm, especially for large sessile serrated lesions (SSLs), but large adenomas should not be candidates for this procedure 3, 4.
Endoscopic Mucosal Resection (EMR)
- EMR is recommended for achieving a completely snare-resected lesion in the safest minimum number of pieces, with adequate margins and without need for adjunctive ablative techniques 2.
- Careful lesion assessment prior to EMR is crucial to identify features suggestive of poor outcome, such as lesion size > 40 mm, ileocecal valve location, prior failed attempts at resection, and size, morphology, site, and access (SMSA) level 4 2.
Treatment Options for the Patient
Given the patient's specific situation, with multiple lesions of varying sizes, the treatment approach should be tailored to the individual characteristics of each lesion.
- For the larger lesions (> 1 cm), cold snare polypectomy (CSP) or hot snare polypectomy (HSP) with submucosal injection could be considered, taking into account the potential risks and benefits of each approach 2, 3.
- For the smaller lesions, CSP is likely a safe and effective option 2, 4.
- EMR could be considered for lesions that are difficult to remove with snare polypectomy alone 2.
Safety and Efficacy Considerations
- The choice of treatment approach should prioritize both safety and efficacy, considering the patient's individual characteristics and the specific features of each lesion 2, 3, 5.
- Recent meta-analyses suggest that CSP is a safe, efficient, and effective technique comparable to EMR, with a lower delayed bleeding rate 5.