Copyright ©2012 Baishideng Publishing Group Co.
World J Gastrointest Endosc. Jul 16, 2012; 4(7): 269-280
Published online Jul 16, 2012. doi: 10.4253/wjge.v4.i7.269
Table 1 Defintion of difficult colon polyp
Shape (morphology)Flat or hard to see
Sessile > 15 mm
Carpet shaped (laterally spreading tumor)
Villous or granular
Irregular surface, irregular pit pattern, villous or granular
If pedunculated, thick or short pedicle
Size< 1.5 cm
Large > 3 cm
Big head
NumberMultiple (> 3)
LocationRight colon and cecum
Ileoceccal valve
Appendix orifice
On top or behind of folds
Difficult endoscopic position
Table 2 Nine steps leading to a successful polypectomy
Locate of the polyp
Analyze the polyp’s shape
Determine the polyp’s size
Analysis of the polyp surface
Determine the number of polyps
Position the polyp before attempting its resection
Estimate polyp respectability using endoscopic methods
Use the submucosal cushion (injection-assisted-polypectomy)
Appropriate skills using clips and/or endoloops
Table 3 Accessories and utensils used in advanced polypectomy
Hot biopsy forceps (we do not recommend to use hot biopsy forceps for colon polyp removal)
Single use
Monofilament and braided wire snares of various diameters, e.g. mini < 11 mm, standard 15-45 mm)
Mini oval (recommended to remove diminutive polyps using the cold-snare technique, i.e. without heat of electrosurgical current)
Standard oval
Mini barbed (the multiple barbs (help hold the tissue inside of the snare)
Needle-tip anchored (the needle tip on top the distal part of the snare helps stabilize the position of the snare, however the tip can lacerate the healthy mucosa)
With heat- resistant net (Nakao net) (not widely available)
Injection needle(s)
Injection substances (normal saline, hypertonic saline, dextrose 50%, adrenaline, sodium hyaluronidate
India ink (used for tattooing and marking)
Dyes (methylene blue, indigo carmine)
Combination needle/snare (allows for injection-assisted polypectomy and immediate snaring)
Rotatable snares (may be useful for polyps located in difficult luminal location, when the scope cannot be torqued to an ideal position)
Endoscopic fitted caps (allow the detection of polyp behind folds)
Without snare rim
With snare rim
Needle knifes (at least 20 different types available for endoscopic submucosal dissection)
Without insulated tip
With insulated tip
Clips (hemoclips or endoclips) (single use or reusable)
Retrieval devices
Nets (Roth net)
Grasping forceps with two to five prongs
Table 4 Technical tips and tricks to improve the resection of difficult colon polpys
Difficult polypsTechnical tips
MorphologySessileUse submucosal cushion
> 1 cmResect in toto (except cecum)
Size and form< 1.5 cmUse diluted epinephrine and Perform piecemeal resection, EMR or ESD
Large (> 3 cm), on top of folds, carpet-like polyp or with villous or granular surface
Use APC for tissue remnants
Big headUse diluted epinephrine in head
Pedunculated (if large)Use clips or loops
Thick pedicleUse clips or loops
MultipleSend to pathologist separately
NumberRight colon and cecumDo not use hot biopsy forceps
Located behind foldsInject distally first
LocationDifficult endoscope positionChange scope to 5 o’clock position
Perform abdominal compression or change patient’s position
Use antispasmodic (e.g., butylscopolamine)
Take air out before catching or snaring the polyp
Resect when going in (if small) or when going out (if large)
Increased colon motilityMark the polyp site with India ink
General recommendationsSuspicious polyp or large, incompletely resected
AbbreviationsAPCArgon plasma coagulation
ESDEndoscopic submucosal dissection
EMREndoscopic mucosal resection