Difficult colon polypectomy

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
Number	Multiple (> 3)
Location	Right 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

Resusable

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

Hexagonal

Crescent

Spiral

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

Flush-knife

Clips (hemoclips or endoclips) (single use or reusable)

Endoloops

Retrieval devices

Baskets

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 polyps	Technical tips
Morphology	Sessile	Use submucosal cushion
	> 1 cm	Resect in toto (except cecum)
Size and form	< 1.5 cm	Use 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 head	Use diluted epinephrine in head
	Pedunculated (if large)	Use clips or loops
	Thick pedicle	Use clips or loops
	Multiple	Send to pathologist separately
Number	Right colon and cecum	Do not use hot biopsy forceps
	Located behind folds	Inject distally first
Location	Difficult endoscope position	Change 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 motility	Mark the polyp site with India ink
General recommendations	Suspicious polyp or large, incompletely resected
Abbreviations	APC	Argon plasma coagulation
	ESD	Endoscopic submucosal dissection
	EMR	Endoscopic mucosal resection

APC: Argon plasma coagulation; ESD: Endoscopic submucosal dissection; EMR: Endoscopic mucosal resection.