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Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.
Endoscopy 2017; 49(3):270-297E

Abstract

1 ESGE recommends cold snare polypectomy (CSP) as the preferred technique for removal of diminutive polyps (size ≤ 5 mm). This technique has high rates of complete resection, adequate tissue sampling for histology, and low complication rates. (High quality evidence, strong recommendation.) 2 ESGE suggests CSP for sessile polyps 6 - 9 mm in size because of its superior safety profile, although evidence comparing efficacy with hot snare polypectomy (HSP) is lacking. (Moderate quality evidence, weak recommendation.) 3 ESGE suggests HSP (with or without submucosal injection) for removal of sessile polyps 10 - 19 mm in size. In most cases deep thermal injury is a potential risk and thus submucosal injection prior to HSP should be considered. (Low quality evidence, strong recommendation.) 4 ESGE recommends HSP for pedunculated polyps. To prevent bleeding in pedunculated colorectal polyps with head ≥ 20 mm or a stalk ≥ 10 mm in diameter, ESGE recommends pretreatment of the stalk with injection of dilute adrenaline and/or mechanical hemostasis. (Moderate quality evidence, strong recommendation.) 5 ESGE recommends that the goals of endoscopic mucosal resection (EMR) are to achieve a completely snare-resected lesion in the safest minimum number of pieces, with adequate margins and without need for adjunctive ablative techniques. (Low quality evidence; strong recommendation.) 6 ESGE recommends careful lesion assessment prior to EMR to identify features suggestive of poor outcome. Features associated with incomplete resection or recurrence include lesion size > 40 mm, ileocecal valve location, prior failed attempts at resection, and size, morphology, site, and access (SMSA) level 4. (Moderate quality evidence; strong recommendation.) 7 For intraprocedural bleeding, ESGE recommends endoscopic coagulation (snare-tip soft coagulation or coagulating forceps) or mechanical therapy, with or without the combined use of dilute adrenaline injection. (Low quality evidence, strong recommendation.)An algorithm of polypectomy recommendations according to shape and size of polyps is given (Fig. 1).

Authors+Show Affiliations

Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Austria. Quality Assurance Working Group of the Austrian Society of Gastroenterology and Hepatology.Department of Endoscopic Services, Western Health, Melbourne, Australia. Department of Medicine, Melbourne Medical School Western Precinct, The University of Melbourne, St. Albans, Victoria, Australia.Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy.Solent Centre for Digestive Diseases, Queen Alexandra Hospital, Portsmouth, UK.Gedyt Endoscopy Center, Buenos Aires, Argentina.Department of Gastroenterology, Benizelion General Hospital, Heraklion, Crete, Greece.Unidad de Gastroenterología, Servicio de Medicina Digestiva, Instituto de Investigación Sanitaria ISABIAL, Hospital General Universitario de Alicante, Alicante, Spain.Department of Pathology, Medical University of Graz, Graz, Austria.Department of Gastroenterology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.Department of Endoscopic Services, Western Health, Melbourne, Australia. Department of Medicine, Melbourne Medical School Western Precinct, The University of Melbourne, St. Albans, Victoria, Australia.Department of Gastroenterology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.Institute of Gastroenterology and Hepatology, Ha'Emek Medical Center, Afula, Israel and Rappaport Family Faculty of Medicine Technion-Israel Institute of Technology, Haifa, Israel.Institute of Gastroenterology and Hepatology, Ha'Emek Medical Center, Afula, Israel and Rappaport Family Faculty of Medicine Technion-Israel Institute of Technology, Haifa, Israel.Quality Assurance Working Group of the Austrian Society of Gastroenterology and Hepatology.Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Austria. Quality Assurance Working Group of the Austrian Society of Gastroenterology and Hepatology.Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Austria. Quality Assurance Working Group of the Austrian Society of Gastroenterology and Hepatology.Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Austria. Quality Assurance Working Group of the Austrian Society of Gastroenterology and Hepatology.Department of Digestive Endoscopy, University Hospital, CHU Fort de France, France.Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands.Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium.Konstantopoulio General Hospital, Athens, Greece.Department of Gastroenterology, Asklepios Klinik Altona, Hamburg, Germany.Department of Endoscopy and Gastroenterology, Edouard Herriot Hospital, Lyon, France.Department of Gastroenterology, Maria Sklodowska-Curie Memorial CancerCenter and Medical Centre for Postgraduate Education, Warsaw, Poland.Humanitas Research Hospital, Humanitas University, Rozzano, Milan, Italy.School of Medicine, Pharmacy and Health, Durham University, Durham, UK.Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia. University of Sydney, Sydney, Australia.Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia. University of Sydney, Sydney, Australia.

Pub Type(s)

Journal Article
Practice Guideline

Language

eng

PubMed ID

28212588

Citation

Ferlitsch, Monika, et al. "Colorectal Polypectomy and Endoscopic Mucosal Resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline." Endoscopy, vol. 49, no. 3, 2017, pp. 270-297.
Ferlitsch M, Moss A, Hassan C, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2017;49(3):270-297.
Ferlitsch, M., Moss, A., Hassan, C., Bhandari, P., Dumonceau, J. M., Paspatis, G., ... Bourke, M. J. (2017). Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy, 49(3), pp. 270-297. doi:10.1055/s-0043-102569.
Ferlitsch M, et al. Colorectal Polypectomy and Endoscopic Mucosal Resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2017;49(3):270-297. PubMed PMID: 28212588.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. AU - Ferlitsch,Monika, AU - Moss,Alan, AU - Hassan,Cesare, AU - Bhandari,Pradeep, AU - Dumonceau,Jean-Marc, AU - Paspatis,Gregorios, AU - Jover,Rodrigo, AU - Langner,Cord, AU - Bronzwaer,Maxime, AU - Nalankilli,Kumanan, AU - Fockens,Paul, AU - Hazzan,Rawi, AU - Gralnek,Ian M, AU - Gschwantler,Michael, AU - Waldmann,Elisabeth, AU - Jeschek,Philip, AU - Penz,Daniela, AU - Heresbach,Denis, AU - Moons,Leon, AU - Lemmers,Arnaud, AU - Paraskeva,Konstantina, AU - Pohl,Juergen, AU - Ponchon,Thierry, AU - Regula,Jaroslaw, AU - Repici,Alessandro, AU - Rutter,Matthew D, AU - Burgess,Nicholas G, AU - Bourke,Michael J, Y1 - 2017/02/17/ PY - 2017/2/18/pubmed PY - 2017/6/27/medline PY - 2017/2/18/entrez SP - 270 EP - 297 JF - Endoscopy JO - Endoscopy VL - 49 IS - 3 N2 - 1 ESGE recommends cold snare polypectomy (CSP) as the preferred technique for removal of diminutive polyps (size ≤ 5 mm). This technique has high rates of complete resection, adequate tissue sampling for histology, and low complication rates. (High quality evidence, strong recommendation.) 2 ESGE suggests CSP for sessile polyps 6 - 9 mm in size because of its superior safety profile, although evidence comparing efficacy with hot snare polypectomy (HSP) is lacking. (Moderate quality evidence, weak recommendation.) 3 ESGE suggests HSP (with or without submucosal injection) for removal of sessile polyps 10 - 19 mm in size. In most cases deep thermal injury is a potential risk and thus submucosal injection prior to HSP should be considered. (Low quality evidence, strong recommendation.) 4 ESGE recommends HSP for pedunculated polyps. To prevent bleeding in pedunculated colorectal polyps with head ≥ 20 mm or a stalk ≥ 10 mm in diameter, ESGE recommends pretreatment of the stalk with injection of dilute adrenaline and/or mechanical hemostasis. (Moderate quality evidence, strong recommendation.) 5 ESGE recommends that the goals of endoscopic mucosal resection (EMR) are to achieve a completely snare-resected lesion in the safest minimum number of pieces, with adequate margins and without need for adjunctive ablative techniques. (Low quality evidence; strong recommendation.) 6 ESGE recommends careful lesion assessment prior to EMR to identify features suggestive of poor outcome. Features associated with incomplete resection or recurrence include lesion size > 40 mm, ileocecal valve location, prior failed attempts at resection, and size, morphology, site, and access (SMSA) level 4. (Moderate quality evidence; strong recommendation.) 7 For intraprocedural bleeding, ESGE recommends endoscopic coagulation (snare-tip soft coagulation or coagulating forceps) or mechanical therapy, with or without the combined use of dilute adrenaline injection. (Low quality evidence, strong recommendation.)An algorithm of polypectomy recommendations according to shape and size of polyps is given (Fig. 1). SN - 1438-8812 UR - https://www.unboundmedicine.com/medline/citation/28212588/Colorectal_polypectomy_and_endoscopic_mucosal_resection__EMR_:_European_Society_of_Gastrointestinal_Endoscopy__ESGE__Clinical_Guideline_ L2 - http://www.thieme-connect.com/DOI/DOI?10.1055/s-0043-102569 DB - PRIME DP - Unbound Medicine ER -