Pattarajierapan S, Takamaru H, Khomvilai S. Difficult colorectal polypectomy: Technical tips and recent advances. World J Gastroenterol 2023; 29(17): 2600-2615 [PMID: 37213398 DOI: 10.3748/wjg.v29.i17.2600]
Corresponding Author of This Article
Sukit Pattarajierapan, MD, Doctor, Surgeon, Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathumwan, Bangkok 10330, Thailand. sukit.p@chulahospital.org
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Minireviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Sukit Pattarajierapan, Supakij Khomvilai, Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
Hiroyuki Takamaru, Endoscopy Division, National Cancer Center Hospital, Tokyo 104-0045, Japan
Author contributions: Pattarajierapan S wrote the article; Takamaru H and Khomvilai S made substantial contributions to the content, offered critical revisions, and approved the final version of the article.
Conflict-of-interest statement: The authors have no conflicts of interest or financial ties to disclose.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Sukit Pattarajierapan, MD, Doctor, Surgeon, Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathumwan, Bangkok 10330, Thailand. sukit.p@chulahospital.org
Received: January 29, 2023 Peer-review started: January 29, 2023 First decision: February 14, 2023 Revised: February 24, 2023 Accepted: April 12, 2023 Article in press: April 12, 2023 Published online: May 7, 2023
Abstract
Colonoscopy has been shown to be an effective modality to prevent colorectal cancer (CRC) development. CRC reduction is achieved by detecting and removing adenomas, which are precursors of CRC. Most colorectal polyps are small and do not pose a significant challenge for trained and skilled endoscopists. However, up to 15% of polyps are considered “difficult”, potentially causing life-threatening complications. A difficult polyp is defined as any polyp that is challenging for the endoscopist to remove owing to its size, shape, or location. Advanced polypectomy techniques and skills are required to resect difficult colorectal polyps. There were various polypectomy techniques for difficult polyps such as endoscopic mucosal resection (EMR), underwater EMR, Tip-in EMR, endoscopic submucosal dissection (ESD), or endoscopic full-thickness resection. The selection of the appropriate modality depends on the morphology and endoscopic diagnosis. Several technologies have been developed to aid endoscopists in performing safe and effective polypectomies, especially complex procedures such as ESD. These advances include video endoscopy system, equipment assisting in advanced polypectomy, and closure devices/techniques for complication management. Endoscopists should know how to use these devices and their availability in practice to enhance polypectomy performance. This review describes several useful strategies and tips for managing difficult colorectal polyps. We also propose the stepwise approach for difficult colorectal polyps.
Core Tip: Most colorectal polyps are small and do not pose a significant challenge to resection. However, up to 15% of polyps are considered “difficult” because of their size, shape, or location. Advanced polypectomy techniques and skills are required for the resection of difficult colorectal polyps. Recent advancements in techniques and devices for endoscopic mucosal resection, endoscopic submucosal dissection, and endoscopic full-thickness resection allow curative therapy of these difficult polyps and avoid unnecessary surgery that carries the risk of morbidity and mortality. However, the proper selection of adjunct endoscopic devices/techniques and stepwise training for skill improvement are critical for successful advanced polypectomy.
