Polypectomy

Does: Polypectomy

• Inspect the polyp carefully
  • Assess size, morphology (pedunculated, sessile, flat), and location
  • Estimate distance from anal verge and check for accessibility
  • Classify the polyp (Paris classification) to guide technique
• Choose the appropriate polypectomy technique
  • Pedunculated polyp → Snare polypectomy
  • Sessile polyp <10 mm → Cold snare or biopsy forceps
  • Sessile polyp 10–20 mm → Cold snare or hot snare
  • Large sessile/flat polyp (>20 mm) → EMR or ESD
• Position the patient and scope to optimise view and access
  • Withdraw slightly to centre the polyp in the field
  • Ideally position the polyp at 6 o’clock
• Inject submucosal cushion
  • Inject saline ± dye (e.g. indigo carmine) ± adrenaline beneath polyp base
  • Confirms non-invasive polyp (if it lifts) and protects deeper layers
• Apply snare around polyp base
  • For pedunculated polyps, loop around stalk as close to the wall as safely possible
  • For sessile polyps, snare the entire base—ensure full capture of tissue
• Check snare position in multiple planes before resection
  • Confirm full enclosure and ensure no muscularis layer is caught
• Apply energy and resect the polyp if using hot snare
  • Use blended or coagulation current depending on preference and polyp size
  • For cold snare, apply steady traction until polyp is sheared
• Retrieve the specimen using suction, trap, or Roth net
  • Always retrieve for histology, even small lesions
• Inspect the resection base carefully
  • Look for residual tissue, bleeding, or exposed vessel
  • Apply endoscopic clips if there’s bleeding or high risk of delayed bleeding (e.g. thick stalk, large vessels, right colon)
• Tattoo the site if the polyp was large, incomplete, or cancer suspected
  • Typically placed 1–2 cm distal to the resection site (in rectum/sigmoid, proximal instead)
• Document the procedure clearly
  • Size, location, morphology, technique, completeness, complications
  • Submit specimen in formalin with correct site labelling

Knows: Advance Polypectomy

Endoscopic Mucosal Resection (EMR)

• Mark the borders
  • Can use argon plasma or coagulation to dot around the lesion, especially for flat lesions or piecemeal resection
• Inject submucosal cushion
  • Saline ± indigo carmine ± adrenaline
  • Creates a safety buffer and improves lift
  • If lesion doesn’t lift (non-lifting sign), suspect submucosal invasion or fibrosis
• Snare resection
  • Ensnare the lifted lesion using a stiff snare
  • For small lesions: en bloc cold or hot snare
  • For larger lesions: piecemeal hot snare resection in sequential segments
• Manage the resection base
  • Remove all visible residual tissue (can use snare tip soft coag or avulsion)
  • Clip the base if bleeding or at risk (especially in right colon)
• Retrieve and label specimens
  • If piecemeal, note number and orientation if possible
  • Tattoo distal to site if surveillance or surgery may be required

Endoscopic Submucosal Dissection (ESD)

• Mark the lesion margins
  • Use coagulation dots 5 mm outside the lesion circumference
  • Ensures clear lateral margin during dissection
• Submucosal injection
  • Lift the lesion using a viscous solution (e.g. hydroxyethyl starch, hyaluronic acid)
  • Use with dye (e.g. indigo carmine or methylene blue) to enhance layer contrast
  • Re-inject as needed during dissection
• Mucosal incision
  • Use a needle knife or insulated-tip knife to incise the mucosa just inside the marking dots
  • Circumferential incision is made around the lesion
• Submucosal dissection
  • Carefully dissect beneath the lesion using an ESD knife (IT knife, DualKnife, etc.)
  • Maintain dissection plane above muscularis propria
  • Manage bleeding with coag forceps or hemostatic devices as needed
  • Proceed slowly with constant injection and visualization
• Resect en bloc
  • The entire lesion is removed in one piece
  • Check the resection base for bleeding or perforation
  • Apply clips if needed
• Specimen retrieval and orientation
  • Pin out flat for histology if possible
  • Submit as en bloc for accurate margin assessment