Endoscopic mucosal resection of large colorectal adenomas: Only for expert centers?

Extent of unnecessary surgery for benign rectal polyps in the Netherlands

“…The value and necessity of increased referral of large, possibly endoscopically treatable polyps to expert centers in EMR and endoscopic submucosal dissection have been questioned in the literature. 16 When analyzing the 2 main reasons for referral to surgery, suspicion of malignancy and size, in more detail, it was remarkable that few features of malignancy were mentioned in the endoscopy reports, except for the polyp size. Descriptions of objective criteria of malignancy, such as the presence of a central excavation, a nongranular nodule, the nonlifting sign, or a Kudo pit pattern type V, were lacking in endoscopy reports of patients referred for surgery.…”

Outcome of EMR as an alternative to surgery in patients with complex colon polyps

“…This may have resulted from the use of a protocol of performing EMR in a clean colon (Boston Bowel Preparation Scale of 8 or 9) and drying up the colon segment to define the lesion better, routine use of a cap fitted colonoscope that facilitated better evaluation and resection of the entire lesion (even it extended over a fold), complete excision of the lesion to create a clean resection base and edges similar to the ones observed after endoscopic submucosal dissection, multiple photographs of the entire resection edge and base that permitted time for careful examination of the entire resection during the freeze mode before a picture was saved, and routine ablation of the edges with argon plasma coagulation. 30, 31 The risk of residual adenoma is higher in those complex polyps ≤ 20 mm (8.3%) compared to those with >20 mm (4.1%). This could be due to referral of smaller tethered lesions after failed prior resections which are difficult to cut completely compared to complete resection of treatment naïve larger lesions.…”