"FAILURE TO LIFT"? AFTER BOWEL WALL INJECTION OF LARGE SESSILE POLYPS: WHAT IS ITS SIGNIFICANCE AS A PREDICTOR OF INVASIVE CANCER IN PATIENTS WITH AND WITHOUT A HISTORY OF PRIOR SNARE USE.
Dasuni Niyagama Gamage*1, Neil Mitra1, Jaspreet Sandhu2, Vesna Cekic1, Shantha Kumara HMC1, Xiaohong Yan1, Richard L. Whelan1
1Surgery, Mount Sinai West Hospital, New York, NY; 2Surgery, Brookdale Hospital Medical Center, Brooklyn, NY
Introduction: Injecting and successfully expanding (or "lifting"?) the submucosal layer of the large bowel wall beneath large sessile adenomas is required prior to the safe performance of Endoscopic Submucosal Dissection (ESD) and Endoscopic Mucosal Resection (EMR). Failure to uniformly lift (FTL) is considered, by some, a contraindication for ESD and EMR because it may be the result of invasion of a cancer into the muscularis propria layer of the bowel wall. Alternately, it may be the result of a prior attempt(s) at snare removal which often results in scar between the polyp and deeper layers. This review assessed the lifting results, subsequent treatment, and final pathology of 120 patients (pts) with large sessile polyps who were assessed in the operating room for possible ESD/EMR vs "wedge"? partial thickness vs segmental resection as part of an IRB approved study.
Methods: Hospital, operative, pathology, and office records were reviewed. The evaluation done at the time of repeat colonoscopy in the operating room included visual inspection of the polyp as well as, in lesions judged amenable to ESD/EMR, an attempt to "lift"? the polyp and the adjacent mucosa via intramural injections was made via sclerotherapy needle. Although not always adhered to, the protocol called for segmental colectomy or partial circumference "wedge"? resection for FTL polyps.
Results: A lift was attempted in 89/120 pts (74%)(reasons for not attempting lift were; ileocecal valve and appendiceal base polyp location(15), cancer highly suspected(8), polyp size/location judged prohibitive(8)). A total of 28/89 polyps (31.5%) did not fully lift when injected. The preop diagnosis in the FTL pts was adenoma alone in 24(86%) and adenoma with high grade dysplasia (HGD) in 4 pts (14%). As per protocol, 21 FTL pts (75%) underwent colectomy without ESD/EMR attempt. The treatment for the remaining 7 pts (25%) was: successful ESD/EMR (5 cases), TEM (1), and transanal removal (1). In 15/28 pts (54%) a prior snare removal attempt had been made. Final pathology revealed invasive cancer in 5 cases (17.9%). The incidence of cancer in FTL pts with prior snare removal attempt was 13% (2/15) vs a rate of 23% (3/13) in FTL pts without past snare use.
Conclusion: In 31.5 % of pts injected the polyp did not fully lift; prior snare use was noted in 54% of FTL pts. The cancer incidence in the FTL prior snare use group (13%) was lower than in FTL polyps without history of past snare use (23%). Failure to lift in prior snare attempt polyps should not be considered a contraindication for ESD/EMR. Further, it is our opinion that endoscopic attempts at removal are also reasonable in polyps without prior snare history since the cancer incidence was not prohibitive provided the patient understands that later colectomy might be needed if the final diagnosis is cancer.
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