Korean J Gastroenterol.  2012 Feb;59(2):85-98. 10.4166/kjg.2012.59.2.85.

Korean Guidelines for Colonoscopic Polypectomy

• Lee SH
• Shin SJ
• Park DI
• Kim SE
• Hong SP
• Hong SN
• Yang DH
• Lee BI
• Kim YH
• Kim HS
• Yang SK
• Kim HJ
• Kim SH
• Kim HJ
• Multi-Society Task Force for Development of Guidelines for Colorectal Polyp Screening, Surveillance and Management

• KMID: 1792820
• DOI: http://doi.org/10.4166/kjg.2012.59.2.85

Abstract

There are indirect evidences to suggest that 80% of colorectal cancers (CRC) develop from adenomatous polyps and that, on average, it takes 10 years for a small polyp to transform into invasive CRC. In multiple cohort studies, colonoscopic polypectomy has been shown to significantly reduce the expected incidence of CRC by 76% to 90%. Colonoscopic polypectomy is performed frequently in primary, secondary and tertiary and medical centers in Korea. However, there are no evidence-based, procedural guidelines for the appropriate performance of this procedure, including the technical aspects. For the guideline presented here, Pubmed, Medline, and Cochrane Library literature searches were performed. When little or no data from well-designed prospective trials were available, an emphasis was placed on the results from large series and reports from recognized experts. Thus, these guidelines for colonoscopic polypectomy are based on a critical review of the available data as well as expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data become available. This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions for any particular case involve a complex analysis of the patient's condition and the available courses of action.

Keyword

Colonoscopy; Polypectomy; Guideline

MeSH Terms

Adenoma/diagnosis/*surgery
Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
Aspirin/therapeutic use
Colonic Polyps/pathology/*surgery
Colonoscopy
Colorectal Neoplasms/diagnosis/*surgery
Databases, Factual
Epinephrine/therapeutic use
Gastrointestinal Hemorrhage/prevention & control
Humans
Lymphatic Metastasis
Republic of Korea
Surgical Instruments
Thrombosis/drug therapy
Vasoconstrictor Agents/therapeutic use

Figure

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  Fig. 1 Efficacy of prophylactic saline with epinephrine injection prior to snare polypectomy for the prevention of overall bleeding (early and late).

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  Fig. 2 Efficacy of prophylactic saline with epinephrine injection prior to snare polypectomy for the prevention of early bleeding.

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  Fig. 3 Efficacy of prophylactic saline with epinephrine injection prior to snare polypectomy for the prevention of late bleeding.

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  Fig. 4 Efficacy of the prophylactic method (endoloop or clip application) for the prevention of early bleeding in cases with large pedunculated polyps.

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  Fig. 5 Efficacy of the prophylactic method (endoloop or clip application) for the prevention of delayed bleeding in cases with large pedunculated polyps.

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  Fig. 6 Subgroup analysis of prophylactic methods vs. submucosal injections for the prevention of early bleeding.

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  Fig. 7 Subgroup analysis of prophylactic methods vs. submucosal injections for the prevention of delayed bleeding.

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  Fig. 8 Subgroup analysis of the prophylactic method vs. no injection for the prevention of early bleeding.

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  Fig. 9 Subgroup analysis of the prophylactic method vs. no injection for the prevention of delayed bleeding.

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  Fig. 10 Efficacy of the prophylactic method (argon plasma coagulation or clip application) for the prevention of delayed bleeding.

Reference

1. Korea Collaborating Center for Cancer Registration. National cancer registry report in 2008. 2010. Seoul: Ministry of Health and Welfare.

2. Guyatt GH, Oxman AD, Vist GE, et al. GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008. 336:924–926.

3. Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. BMJ. 2004. 328:1490.

4. Komatsu T, Tamai Y, Takami H, Yamagata K, Fukuda S, Munakata A. Study for determination of the optimal cessation period of therapy with anti-platelet agents prior to invasive endoscopic procedures. J Gastroenterol. 2005. 40:698–707.

5. Anderson MA, Ben-Menachem T, Gan SI, et al. ASGE Standards of Practice Committee. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009. 70:1060–1070.

6. Cannegieter SC, Rosendaal FR, Briët E. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation. 1994. 89:635–641.

7. Stein PD, Alpert JS, Copeland J, Dalen JE, Goldman S, Turpie AG. Antithrombotic therapy in patients with mechanical and biological prosthetic heart valves. Chest. 1992. 102:4 Suppl. 445S–455S.

8. Shiffman ML, Farrel MT, Yee YS. Risk of bleeding after endoscopic biopsy or polypectomy in patients taking aspirin or other NSAIDS. Gastrointest Endosc. 1994. 40:458–462.

9. Kim HS, Kim TI, Kim WH, et al. Risk factors for immediate postpolypectomy bleeding of the colon: a multicenter study. Am J Gastroenterol. 2006. 101:1333–1341.

10. Yousfi M, Gostout CJ, Baron TH, et al. Postpolypectomy lower gastrointestinal bleeding: potential role of aspirin. Am J Gastroenterol. 2004. 99:1785–1789.

11. Hui AJ, Wong RM, Ching JY, Hung LC, Chung SC, Sung JJ. Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: analysis of 1657 cases. Gastrointest Endosc. 2004. 59:44–48.

12. Sawhney MS, Salfiti N, Nelson DB, Lederle FA, Bond JH. Risk factors for severe delayed postpolypectomy bleeding. Endoscopy. 2008. 40:115–119.

13. Rex DK, Helbig CC. High yields of small and flat adenomas with high-definition colonoscopes using either white light or narrow band imaging. Gastroenterology. 2007. 133:42–47.

14. Kahi CJ, Anderson JC, Waxman I, et al. High-definition chromocolonoscopy vs. high-definition white light colonoscopy for average-risk colorectal cancer screening. Am J Gastroenterol. 2010. 105:1301–1307.

15. Hewett DG, Rex DK. Colonoscopy and diminutive polyps: hot or cold biopsy or snare? Do I send to pathology? Clin Gastroenterol Hepatol. 2011. 9:102–105.

16. Vanagunas A, Jacob P, Vakil N. Adequacy of "hot biopsy" for the treatment of diminutive polyps: a prospective randomized trial. Am J Gastroenterol. 1989. 84:383–385.

17. Peluso F, Goldner F. Follow-up of hot biopsy forceps treatment of diminutive colonic polyps. Gastrointest Endosc. 1991. 37:604–606.

18. Woods A, Sanowski RA, Wadas DD, Manne RK, Friess SW. Eradication of diminutive polyps: a prospective evaluation of bipolar coagulation versus conventional biopsy removal. Gastrointest Endosc. 1989. 35:536–540.

19. Efthymiou M, Taylor AC, Desmond PV, Allen PB, Chen RY. Biopsy forceps is inadequate for the resection of diminutive polyps. Endoscopy. 2011. 43:312–316.

20. Mann NS, Mann SK, Alam I. The safety of hot biopsy forceps in the removal of small colonic polyps. Digestion. 1999. 60:74–76.

21. Tappero G, Gaia E, De Giuli P, Martini S, Gubetta L, Emanuelli G. Cold snare excision of small colorectal polyps. Gastrointest Endosc. 1992. 38:310–313.

22. Tsai CJ, Lu DK. Small colorectal polyps: histopathology and clinical significance. Am J Gastroenterol. 1995. 90:988–994.

23. Wadas DD, Sanowski RA. Complications of the hot biopsy forceps technique. Gastrointest Endosc. 1988. 34:32–37.

24. Mönkemüller KE, Fry LC, Jones BH, Wells C, Mikolaenko I, Eloubeidi M. Histological quality of polyps resected using the cold versus hot biopsy technique. Endoscopy. 2004. 36:432–436.

25. Rohde H, Guenther MW, Budde R, Mühlhofer H. Randomized trial of prophylactic epinephrine-saline injection before snare polypectomy to prevent bleeding. Endoscopy. 2000. 32:1004–1005.

26. Hsieh YH, Lin HJ, Tseng GY, et al. Is submucosal epinephrine injection necessary before polypectomy? A prospective, comparative study. Hepatogastroenterology. 2001. 48:1379–1382.

27. Di Giorgio P, De Luca L, Calcagno G, Rivellini G, Mandato M, De Luca B. Detachable snare versus epinephrine injection in the prevention of postpolypectomy bleeding: a randomized and controlled study. Endoscopy. 2004. 36:860–863.

28. O'Brien JR. Some effects of adrenalin and anti-adrenaline compounds on platelets in vitro and in vivo. Nature. 1963. 200:763–764.

29. Randall GM, Jensen DM, Hirabayashi K, Machicado GA. Controlled study of different sclerosing agents for coagulation of canine gut arteries. Gastroenterology. 1989. 96:1274–1281.

30. LeVeen HH, Diaz C, Falk G, et al. A proposed method to interrupt gastrointestinal bleeding: preliminary report. Ann Surg. 1972. 175:459–465.

31. Dobrowolski S, Dobosz M, Babicki A, Głowacki J, Nałecz A. Blood supply of colorectal polyps correlates with risk of bleeding after colonoscopic polypectomy. Gastrointest Endosc. 2006. 63:1004–1009.

32. Watabe H, Yamaji Y, Okamoto M, et al. Risk assessment for delayed hemorrhagic complication of colonic polypectomy: polyp-related factors and patient-related factors. Gastrointest Endosc. 2006. 64:73–78.

33. Hachisu T. A new detachable snare for hemostasis in the removal of large polyps or other elevated lesions. Surg Endosc. 1991. 5:70–74.

34. Kouklakis G, Mpoumponaris A, Gatopoulou A, Efraimidou E, Manolas K, Lirantzopoulos N. Endoscopic resection of large pedunculated colonic polyps and risk of postpolypectomy bleeding with adrenaline injection versus endoloop and hemoclip: a prospective, randomized study. Surg Endosc. 2009. 23:2732–2737.

35. Paspatis GA, Paraskeva K, Theodoropoulou A, et al. A prospective, randomized comparison of adrenaline injection in combination with detachable snare versus adrenaline injection alone in the prevention of postpolypectomy bleeding in large colonic polyps. Am J Gastroenterol. 2006. 101:2805.

36. Iishi H, Tatsuta M, Narahara H, Iseki K, Sakai N. Endoscopic resection of large pedunculated colorectal polyps using a detachable snare. Gastrointest Endosc. 1996. 44:594–597.

37. Nelson DB, McQuaid KR, Bond JH, Lieberman DA, Weiss DG, Johnston TK. Procedural success and complications of large-scale screening colonoscopy. Gastrointest Endosc. 2002. 55:307–314.

38. Waye JD, Lewis BS, Yessayan S. Colonoscopy: a prospective report of complications. J Clin Gastroenterol. 1992. 15:347–351.

39. Lee CK, Lee SH, Park JY, et al. Prophylactic argon plasma coagulation ablation does not decrease delayed postpolypectomy bleeding. Gastrointest Endosc. 2009. 70:353–361.

40. Shioji K, Suzuki Y, Kobayashi M, et al. Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy. Gastrointest Endosc. 2003. 57:691–694.

41. Cooper HS. Surgical pathology of endoscopically removed malignant polyps of the colon and rectum. Am J Surg Pathol. 1983. 7:613–623.

42. Coverlizza S, Risio M, Ferrari A, Fenoglio-Preiser CM, Rossini FP. Colorectal adenomas containing invasive carcinoma. Pathologic assessment of lymph node metastatic potential. Cancer. 1989. 64:1937–1947.

43. Hassan C, Zullo A, Risio M, Rossini FP, Morini S. Histologic risk factors and clinical outcome in colorectal malignant polyp: a pooled-data analysis. Dis Colon Rectum. 2005. 48:1588–1596.

44. Kyzer S, Bégin LR, Gordon PH, Mitmaker B. The care of patients with colorectal polyps that contain invasive adenocarcinoma. Endoscopic polypectomy or colectomy? Cancer. 1992. 70:2044–2050.

45. Yamamoto S, Watanabe M, Hasegawa H, et al. The risk of lymph node metastasis in T1 colorectal carcinoma. Hepatogastroenterology. 2004. 51:998–1000.

46. Egashira Y, Yoshida T, Hirata I, et al. Analysis of pathological risk factors for lymph node metastasis of submucosal invasive colon cancer. Mod Pathol. 2004. 17:503–511.

47. Tominaga K, Nakanishi Y, Nimura S, Yoshimura K, Sakai Y, Shimoda T. Predictive histopathologic factors for lymph node metastasis in patients with nonpedunculated submucosal invasive colorectal carcinoma. Dis Colon Rectum. 2005. 48:92–100.

48. Yasuda K, Inomata M, Shiromizu A, Shiraishi N, Higashi H, Kitano S. Risk factors for occult lymph node metastasis of colorectal cancer invading the submucosa and indications for endoscopic mucosal resection. Dis Colon Rectum. 2007. 50:1370–1376.

49. Ishikawa Y, Akishima-Fukasawa Y, Ito K, Akasaka Y, Yokoo T, Ishii T. Toho Study Group for Cancer Biological Behavior. Histopathologic determinants of regional lymph node metastasis in early colorectal cancer. Cancer. 2008. 112:924–933.

50. Tateishi Y, Nakanishi Y, Taniguchi H, Shimoda T, Umemura S. Pathological prognostic factors predicting lymph node metastasis in submucosal invasive (T1) colorectal carcinoma. Mod Pathol. 2010. 23:1068–1072.

51. Kitajima K, Fujimori T, Fujii S, et al. Correlations between lymph node metastasis and depth of submucosal invasion in submucosal invasive colorectal carcinoma: a Japanese collaborative study. J Gastroenterol. 2004. 39:534–543.