Difficult Polyps Research Articles

Difficult colorectal polypectomy: Technical tips and recent advances.

Colonoscopy has been shown to be an effective modality to prevent colorectal cancer (CRC) development. CRC reduction is achieved by detecting and removing adenomas, which are precursors of CRC. Most colorectal polyps are small and do not pose a significant challenge for trained and skilled endoscopists. However, up to 15% of polyps are considered "difficult", potentially causing life-threatening complications. A difficult polyp is defined as any polyp that is challenging for the endoscopist to remove owing to its size, shape, or location. Advanced polypectomy techniques and skills are required to resect difficult colorectal polyps. There were various polypectomy techniques for difficult polyps such as endoscopic mucosal resection (EMR), underwater EMR, Tip-in EMR, endoscopic submucosal dissection (ESD), or endoscopic full-thickness resection. The selection of the appropriate modality depends on the morphology and endoscopic diagnosis. Several technologies have been developed to aid endoscopists in performing safe and effective polypectomies, especially complex procedures such as ESD. These advances include video endoscopy system, equipment assisting in advanced polypectomy, and closure devices/techniques for complication management. Endoscopists should know how to use these devices and their availability in practice to enhance polypectomy performance. This review describes several useful strategies and tips for managing difficult colorectal polyps. We also propose the stepwise approach for difficult colorectal polyps.

Planning management for complex colorectal polyps: a qualitative assessment of factors influencing decision-making among colonoscopists

ObjectiveEndoscopic therapy is the recommended primary treatment for most complex colorectal polyps, but high colonic resection rates are reported. The aim of this qualitative study was to understand and compare...

S136 Real World Validation of an Artificial Intelligence Characterization Support System for Prediction of Polyp Histology in Colonoscopy: Interim Analysis of a Prospective Multicenter Study

Introduction: Colonoscopy is the gold standard for screening of colorectal cancer. Diminutive and hyperplastic polyps do not increase a patient’s risk for colorectal cancer. Prediction of hyperplastic polyp histology is crucial for the resect and discard strategy, which saves cost and decreases procedure time in colonoscopy. This study aims to validate the performance of computer-aided diagnosis (CADx) in distinguishing between hyperplastic and neoplastic polyps during colonoscopy in a real-world setting. Methods: We conducted a prospective multicentre study comparing CADx (Fujifilm Corp., Tokyo) with endocopist optical prediction of polyp histology. We first recorded the optical diagnosis according to the NICE classification by the endoscopist. Following this, the CADx tool was switched on and its prediction recorded. Imaged polyps were resected for histological analysis, which formed the gold standard. Primary outcome was diagnostic accuracy (defined by sensitivity for diagnosis of hyperplastic polyps and concordance rate). Bowel preparation, polyp size and difficulty in location were recorded for subgroup analysis. Results: 414 patients were assessed for eligibility across 4 large tertiary institutions in Singapore between February 2021 and June 2022. 625 polyps (303 hyperplastic, 322 neoplastic) were detected in 257 patients. Concordance rates for CADx and endoscopist predictions were 74.1% [95% confidence interval (CI) 70.5%-77.5%] and 73.1% (95% CI 69.5%-76.6%%), respectively (p=NS). Sensitivity for diagnosis of hyperplastic polyps was 84.2% (95% CI 79.6%-88.1%) and 77.6% (95% CI 72.4%-82.1%) for CADx and endoscopists, respectively (p=NS). CADx also showed superior performance in predicting hyperplastic histology in diminutive polyps compared to endoscopist optical prediction using the NICE classification (sensitivity 81.7%; 95% CI 76.2%-86.4%, versus 76.3%; 95% CI 70.4%-81.5%, respectively). Diagnostic accuracy was similar when analysed according to bowel preparation and difficulty in polyp location during colonoscopy (defined as polyp location behind fold, around bend, or unable to position at 6 o’clock). Conclusion: CADx showed a trend towards increased diagnostic accuracy in prediction of hyperplastic polyp histology during colonoscopy compared to endoscopist prediction in this interim analysis. The superior performance in sensitivity for disgnosis of hyperplastic polyps was also seen in diminutive polyps, but not with poor bowel preparation and difficult polyp location.

Combination of a dynamic rigidizing overtube and a novel injectable needle-type knife to facilitate colorectal endoscopic submucosal dissection.

Video 1Combination of a dynamic rigidizing overtube and a novel injectable needle-type knife to facilitate colorectal endoscopic submucosal dissection.

2939 Outcomes of Patients With Large Colonic Polyps Referred to a Tertiary Center for Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection

INTRODUCTION: Large colonic polyps (>2 cm), flat or sessile, are difficult to remove by endoscopy. These difficult polyps are usually referred to experienced advanced endoscopists for endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). There is no data regarding outcomes of referred polypectomies to a tertiary care center for endoscopic management. We aimed to examine outcomes of patients referred to a tertiary center for EMR and ESD and thereby provide feedback to referring physicians. METHODS: A retrospective study of patients with difficult polyps referred to an experienced advanced endoscopist at a large academic center for EMR and ESD between February 2016-August 2018 was completed. 141 referred patients were enrolled. Charts were reviewed for outcomes including: procedure setting, procedure type, need for surgical consult, duration, complete removal, complications, antibiotic use, hospital days, pathology, and repeat colonoscopy findings. RESULTS: The average size of referred polyps was 3.39 cm, with most being flat or sessile. Procedures were largely performed in the surgical ambulatory center. EMR constituted the majority of procedures, followed by ESD, and snare cautery polypectomy. Complete removal with first session colonoscopy was originally noted with 87% of polyps. For this group, mean procedure time was 47 minutes with a complication rate of 8.9%, consisting mainly of hematochezia. Of this subset of patients, 46.4% had a repeat colonoscopy/pathology at time of study with majority of findings unremarkable. When accounting for residual polyps on repeat colonoscopy, 62.4% of patients had complete removal at first colonoscopy. Overall, 7.8% required a surgical consult. Most patients did not require hospitalization after procedure or antibiotics. Comparative analysis revealed no significant difference between different techniques. CONCLUSION: Most polypectomies referred to an experienced advanced endoscopist for EMR and ESD can be performed in an outpatient ambulatory surgical center. Most of the polyps were removed by EMR. ESD was performed in a small percentage of patients. Currently there are no guide lines regarding what kind of polyps should be referred. The majority of referred difficult polyps were completed removed at the first colonoscopy within a relatively short procedure time. At least a portion of those polyps should be able to be resected at the index colonoscopy, without referral, to reduce health care cost and patient inconvenience.

1655 Removal of a 6CM Appendiceal Orifice Polyp With Snare Cautery Polypectomy

INTRODUCTION: Appendiceal orifice (AO) polyps are uncommon. They are usually removed surgically due to technical difficulties and high risk of perforation with endoscopic intervention. In the following case we present a patient with a 6 cm AO polyp removed successfully with snare cautery technique during colonoscopy. CASE DESCRIPTION/METHODS: A 66-year-old man presented to our clinic for colorectal cancer screening. During colonoscopy, careful inspection of the AO revealed a subtle bulge. A submucosal injection of the AO using Eleview revealed a 6cm cauliflower-like lesion. The AO polyp was then removed with snare cautery polypectomy technique without any complications. The edges were approximated with endoscopic mechanical clips. Biopsy results showed tubular adenoma without dysplasia. DISCUSSION: The majority of AO polyps are removed surgically due to potential complications, especially perforation. Currently, there are no guidelines that discuss management of these polyps due to lack of available data. A retrospective study involving 131 patients from multiple tertiary centers showed that polyps more than 20 mm in size undergoing endoscopic resection had significantly higher rates of perforation. Another retrospective study of 691 patients found that AO polyps greater than 5 mm in size were more likely to require surgery. Additionally, it has been reported that AO polyps encompassing more than 75% circumference have low resection rates. To our knowledge, this case is one of the largest endoscopic removal of an AO polyp encompassing the majority of the AO circumference without complications. Although traditionally AO polyps are removed surgically, our case suggests an alternative, less invasive and effective method of removing these difficult polyps. In order to validate our claim, documentation of more cases would be required.

Large colon polyps: endoscopic resection or colectomy?

Background: Endoscopic polypectomy is an accepted procedure for prevention of colorectal cancer. Yet, large and difficult polyps present a technical and medical challenge to correct treatment. Objective: The aim of this study was to report and analyze the experience in the treatment of large colon polyps. Material and methods: We analyzed the endoscopic resection of large colon polyps performed between January 2006 and March 2018. Results: Of 3397 lower gastrointestinal endoscopies, 22 patients underwent resection of 25 large polyps (0.64%). There were no complications or deaths in the series. Conclusions: Endoscopic resection of large colon polyps is feasible and safe in lesions > 20 mm in diameter. The procedure serves both as biopsy or definite treatment and is an additional tool for the surgeon who has the capability of dealing with the complications or completing with surgery.

CT colonography interpretation: how to maximize polyp detection and minimize overcalling

This article outlines how to achieve maximum accuracy in interpreting CT colonography (CTC) regarding colonic findings. Interpreting extracolonic findings seen on CTC is a separate diagnostic task and will not be addressed in this article. While many interpretive pitfalls are in fact related to CTC techniques, this article focuses on issues that are related to interpretive knowledge and skills, avoiding in-depth discussions on CTC techniques. Principal methods and further tips for detecting possible polyp candidates and for confirming true soft-tissue polyps will be discussed. Specific points about optimizing interpretation strategies for difficult flat polyps including sessile serrated polyp will be raised. There are numerous interpretive pitfalls regarding the colonic interpretation of CTC. Knowledge of these pitfalls will shorten the learning curve and help achieve accurate reads.

Combined Endoscopic Laparoscopic Surgery Procedures for Colorectal Surgery

Colonoscopy is the standard of care for screening and surveillance of colorectal cancers. Removal of adenomatous polyps prevents the transformation of adenomas to potential adenocarcinoma. While most polyps are amenable to simple endoscopic polypectomy, difficult polyps that are large, broad-based, or located in haustral folds or in tortuous colon segments can present a challenge for endoscopists. Traditionally, patients with endoscopically unresectable polyps have been referred for oncologic surgical resection due to the underlying risk of malignancy within the polyp; however, the majority of these polyps are benign on final pathology. Combined endoscopic laparoscopic surgery can help facilitate endoscopic removal of difficult lesions, or allow the surgeon to select the correct laparoscopic approach for polyp excision. Current literature suggests that these procedures are safe and effective and can potentially save patients from the morbidity of laparotomy and segmental colectomy.

Insulated-tip knife endoscopic polypectomy for difficult pedunculated colorectal polyps: a prospective pilot study.

Endoscopic polypectomy is widely used for colorectal polyps. However, for giant pedunculated colorectal polyps (≥3cm), conventional techniques are so difficult with en bloc resection that patients had to be transferred to surgery. We had firstly reported our first experience with an insulated-tip knife to successfully remove a giant pedunculated polyp in the sigmoid colon. In this study, our aim was to explore safety and feasible of insulated-tip knife endoscopic polypectomy (IT-EP) for difficult pedunculated colorectal polyps. A total of seven consecutive patients with giant pedunculated colorectal polyps (≥3cm) were prospectively enrolled. IT-EP was conducted with the help of clips for all the seven patients, and data of them was recorded and analyzed. Of seven patients, five were men and two were women with a mean age 61years (49-72years). The mean diameter of polyp head and stalk was 36.4±4.9mm (30-42mm) and 14.6±3.6mm (10-20mm), respectively. All the polyps were successfully removed with IT-EP, with a mean operation time of 14.9±3.5min (11-20min). No serious bleeding or perforation was experienced, and no surgery was needed. There was no recurrence or residual of polyps at a mean 8.1-month follow-up. Insulated-tip knife endoscopic polypectomy is a safe and feasible alternative for difficult pedunculated colorectal polyps.

Dynamic Article: Full-Thickness Excision for Benign Colon Polyps Using Combined Endoscopic Laparoscopic Surgery.

Benign colon polyps are commonly encountered but may not always be amenable to endoscopic excision because of their size, shape, location, or scarring from previous attempts. The addition of laparoscopy allows a greater degree of bowel manipulation, but the current technique is still limited when encountering a polyp with inadequate lifting attributed to polyp morphology or scarring. We describe an extension to the existing combined endoscopic laparoscopic surgery technique using a full-thickness approach to increase polyp maneuverability and local excision of difficult but benign polyps. The purpose of this study was to report the technical details and preliminary results of a new approach for full-thickness excision of difficult colon polyps, combined endoscopic laparoscopic surgery full-thickness excision. This study is a retrospective review of our experience from December 2013 to May 2015. The study was conducted at a single academic institution. All of the patients had previous incomplete colonoscopic polypectomy performed at other institutions. Patients were selected for our technique if the polyp had a benign appearance but was unable to be resected by traditional endoscopic or combined endoscopic laparoscopic surgery methods because of polyp morphology or scarring from previous biopsies. The safety and feasibility of this procedure were measured. Three patients underwent combined endoscopic laparoscopic surgery-full-thickness excision for difficult colon polyps. There were no intraoperative or postoperative complications. The length of stay was 1 day for all of the patients. All 3 of the patients had benign final pathology. This study was limited by the small number of patients in a single institution. Full-thickness excision for benign colon polyps using combined endoscopic laparoscopic surgery is safe and feasible. Using this technique, difficult polyps not amenable to traditional endoscopic approaches can be removed and colectomy may be avoided.

Small Polyps at Endoluminal CT Colonography Are Often Seen But Ignored by Radiologists.

The objective of our study was to describe the characteristics of polyps viewed but then dismissed incorrectly by radiologists at endoluminal CT colonography (CTC), eye movements during these errors, and features provoking false-positive diagnoses. Forty-two radiologists viewed 30 endoluminal CTC videos, each depicting a polyp, while their eye movements were tracked. Half of the videos had computer-assisted detection (CAD), and half did not. Classification errors were defined when proven polyps were seen but dismissed. Eye movements during these errors and during correct polyp identifications were compared with multilevel modeling. Polyps were divided subsequently into "difficult to classify" and "easy to classify" using a classification error threshold of more than 15%. Polyp diameter, height, and subjective conspicuity and the proportion of time viewed were compared between groups. Eye tracking revealed that 97% of false-negative polyp diagnoses were nonetheless preceded by the reader observing the polyp. The difficult polyps were significantly smaller than the easy polyps (mean diameter, 5.4 vs 8.2 mm, respectively p = 0.014) and were subjectively less conspicuous (median score, 4 vs 2; p = 0.0032). Readers spent proportionally less time viewing difficult polyps than viewing easy polyps (29.0% of the time they were on-screen vs 42.6%, respectively; p = 0.01) regardless of the presence of CAD. Even small and subjectively inconspicuous polyps attract reader gaze, but they are nonetheless ignored. These errors are made rapidly even with CAD. Efforts to improve reader performance at CTC should focus on decision making rather than detection alone.

Frequency of and risk factors for the surgical resection of nonmalignant colorectal polyps: a population-based study.

The management of patients with colon polyps who are referred to surgery remains uncharacterized in a population-based setting. The aims of this study were to determine the frequency, risk factors, and outcomes of patients referred for surgical resection of colorectal polyps. All patients who underwent a colonoscopy for positive fecal occult blood test in the setting of a population-based colorectal cancer screening program in France between 2003 and 2012 were analyzed. The primary outcome was the proportion of patients undergoing colorectal surgery for polyps without invasive carcinoma. Logistic regression analysis was applied to identify risk factors for surgical resection. Among 4251 patients with at least one colorectal polyp, 175 (4.1 %) underwent colorectal surgery. Risk factors for surgery included size, proximal polyp location, advanced histology (villous or high grade dysplasia), the endoscopy center, and colonoscopy performed during the first half of the study period. Subgroup analysis of 3475 colonoscopies performed by 22 endoscopists who performed at least 50 colonoscopies during the study period, identified the endoscopist as an additional risk factor. The adjusted proportions of referrals to surgery ranged from 0 to 46.6 % per endoscopist for polyps ≥ 20 mm (median 20.2 %). Overall, surgical complications occurred in 24.0 %, and one patient died following surgery (0.5 %). None of the 175 patients who underwent surgery were referred to a tertiary endoscopic center prior to surgery. In this population-based study, 4.1 % of patients with nonmalignant polyps were referred for surgical resection. The endoscopist was one important factor that was associated with surgical referral. To further decrease the proportion of inappropriate surgery in patients, endoscopists should refer their patients with large or difficult polyps to expert endoscopists prior to surgery.

PWE-363 Bowelscope- results from the pilot sites: Abstract PWE-363 Table 1

Introduction A large UK study of single flexible sigmoidoscopy with adenoma clearance in patients aged 55–64, demonstrated a reduction in CRC incidence by 23% and mortality by 31% in intention-to-treat analyses. 1 This provided the rationale for provision of a new arm of the Bowel Cancer Screening Programme (BCSP), offering a single flexible sigmoidoscopy (FS) to all 55 year olds in England, known as BowelScope screening. BowelScope was introduced to 6 pilot sites, beginning in May 2013. It is to be rolled out across the country by 2016. Method We aim to describe the findings, in terms of procedural data, from the first year of BowelScope screening at the pilot sites. Data were obtained from the Bowel Cancer Screening System database for all participants who underwent FS between May 2013–May 2014. Procedural data were recorded, including entonox use, adenoma detection rate (ADR), cancer detection, complications and colonoscopy conversion rates. Results Overall uptake was 44.1%. 1 cancer was detected. Mean ADR was 9.2%. The mean number of patients requiring colonoscopy conversion was 4.2%. Mean complication rate was 0.1%, including bleeding, discomfort, difficult polyp excision and unwell patient. There was wide variation in entonox use. (Table 1). Conclusion Uptake has improved since the six month data were presented but remains lower than for the FOB arm of the BCSP, and varies between sites. The ADR is 9.2% (range 7.6% - 11.1%). This is lower than reported in the UK FS screening trial (12.1%) 1 , however ADR calculations in BowelScope do not include adenomas not removed at FS but removed later at colonoscopy, whereas the FS trial did. The ADR is comparable to the BowelScope pathfinder project (9.6%). 2 Further work is necessary to explore the variation in uptake rates. Variation in ADR exists between centres. Further analysis of endoscopist factors and patient groups may explain this. Entonox use varies widely but does not appear to correlate with ADR- further work may be required to investigate this. Disclosure of interest None Declared. References Atkin WS et al . Lancet 2010;375:1624–33 Bevan R et al . Endoscopy 2015;47(3):225–31

PTH-040 Laparoscopic-assisted colonoscopic polypectomy is a safe and effective option for difficult polyps: a single tertiary referral centre experience

<h3>Introduction</h3> Colonic polyps deemed difficult to access or resect at endoscopy are often referred for surgical resection. We report our experience using laparoscopic assisted colonoscopic polyp resection at a single tertiary referral centre. <h3>Method</h3> Combined procedures from 2012 to 2014 for patients referred for resection of colonic polypsons deemed not amenable for safe endoscopic resection or where access was difficult, and therefore planned for laparoscopic assistance, were analysed. Clinical data regarding primary lesion, reason for referral for laparoscopic assistance, and outcomes were recorded. <h3>Results</h3> 15 patients have so far been planned for laparo-endoscopic procedures following multidisciplinary meetings, of whom 1 patient proceeded with surgery alone. 14 patients, with median age 73.0 years (range 35.7–85.1 years) were studied. The main reasons for laparoscopic assistance were: large high risk polyps, unfavourable location and the presence of diverticular disease. The median size of the polyps was 5 cm (range 2.3–15 cm). All procedures were performed under general anaesthetic. Completion of colonoscopic resection was performed with surgical presence without laparoscopic assistance in one. Laparoscopic adhesiolysis was performed in 5 patients to facilitate access. Seven patients required surgical resection (laparoscopic right hemicolectomy in 6 and sigmoid resection in 1). A cancer was confirmed histologically in 3 of these patients, with the other four being adenomas with high-grade dysplasia (HGD, 1) or low grade dysplasia (LGD, 3). In the remaining 7 patients, complete polypectomy was achieved, with histopathology showing adenomas with HGD (2), LGD (1), and lipomas in 3 patients with submucosal lesions, and non-diagnostic material in one patient. Median post-operative length of stay was 2 days (range 1 to 5 days) following colonoscopic resection, and uncomplicated except for post-polypectomy syndrome in one patient. Three of these patients have been followed-up to 6 months, with no recurrence of the lesion seen. Amongst patients requiring surgical resection, length of stay was longer (median 6 days [range 3–21 days], p = 0.002, Mann Whitney), with one patient suffering from anastomotic leak and another from an intra-abdominal fluid collection managed conservatively. <h3>Conclusion</h3> Attempted laparoscopic-assisted colonoscopic polypectomy is an effective strategy in a selected patients, enabling safe and complete polypectomy for lesions that are difficult to resect at primary colonoscopy. This approach may help to reduce surgical morbidity and reduce length of hospital stay. <h3>Disclosure of interest</h3> None Declared.

PTH-041 Large (&lt;4 cm) and giant (≥4 cm) colorectal polyps: comparison of piecemeal resection outcomes

Introduction Piecemeal Endoscopic Mucosal Resection (p-EMR) is a standard and safe endoscopic technique for resection of large colorectal polyps (>2 cm). Limited data are available regarding p-EMR of giant polyps (>4 cm). Method A prospective study recording short and long-term outcomes after p-EMR for colorectal polyps > 2 cm between Jan 2010 and August 2012 was conducted. We compared two cohorts of patients: group-A with large polyps (2 to Results Group-B patients were older than group-A patients (mean 70.6 vs. 67.8 yrs, p = 0.01) and were more likely to have come from a tertiary referral source (p = 0.05). Large polyp referrals were almost twice as frequent as giant polyp referrals (218 vs. 123, p Endoscopic excision was complete in 89% in large (median time 18min) and in 70% in giant groups (median time 38min). All large polyps were excised in one session, whilst 4% of giant polyps required more than one session. Incomplete submucosal lift (46% vs 63%, p = 0.002) and difficult polyp position (45% vs 63%, p Conclusion Piecemeal resection is a safe and efficacious modality for the resection of colorectal polyps >4 cm. However, these giant polyps more often require spiral snare or hybrid resection techniques and their higher adenoma recurrence rate post p-EMR may dictate shorter surveillance intervals. Disclosure of interest None Declared.

Sa1553 Laparoscopic-Assisted Colonoscopic Polypectomy Is a Safe and Effective Option for Difficult Polyps: a Single Tertiary Referral Centre Experience

Colonic polyps deemed difficult to access or resect at endoscopy are often referred for surgical segmental resection. We report experience using laparoscopic assistance for colonoscopic polyp resection at a single tertiary referral centre.

How to Get Unstuck: Difficult Polypectomy Involving a Solitary Cecal Ganglioneuroma

Introduction: Ganglioneuromas are benign central nervous system tumors that originate from sympathetic ganglion cells. Gastrointestinal ganglioneuromas (GN) are exceedingly rare, and prognosis is excellent with complete excision. We report the case of a patient with a cecal polyp proven to be GN after a difficult polypectomy. Case Report: A 54-year-old male with no significant medical history underwent EGD and colonoscopy for fatigue and weight loss. EGD was unremarkable, and colonoscopy showed a 7-mm cecal polyp near the appendiceal orifice. Based on size, location, and endoscopic appearance of the polyp, a decision was made to use hot snare. The polypectomy was unusual, as the snare loop kept getting stuck around the polyp instead of a routine transection. All equipment was checked immediately and noted to be working appropriately. Placement of the snare appeared to be in place around the base of the polyp and it was successfully removed after the third attempt; no bleeding was noted at the site. Conclusion: We report this case of a rare gastrointestinal GN associated with difficult polypectomy. Evidence suggests most colonic GN’s are found in the left colon and rectum, which makes our case more unique. The polypectomy itself was challenging, and we have outlined below some steps to help assure successful removal of a difficult polyp in a methodical way. Transection of a polyp is achieved by 2 forces: heat and mechanical shearing force. We recommend first reassessing the thickness of the stalk and type of snare, and confirming the correct endoscopic placement and position of the snare, followed by checking the connections and setting of the electrosurgical unit, foot plate position, and slide handle bar action, and finally confirming that adequate force is being applied. If the force is not adequate during the wire loop closure, the snare will not cut through the captured tissue despite adequate electrical current. Lack of force to pull the wire through the tissue will cause a stuck snare. To avoid this, and to ensure adequate shearing force, the tip of the snare wire must retract at least 1.5 cm into the sheath when the handle is completely closed. If this margin is not attained, part of the wire loop may remain outside the sheath tip when it is closed around a large polyp, despite the snare handle being completely closed. In this situation, thermal energy will cause the tissue encapsulated within the loop to become dessicated, leading to an incarcerated snare. Once the polyp has been properly looped with the snare, electrocoagulate using low-power coagulating current continuously for 10-15 seconds at a time.

908 Avulsion: a Novel Technique to Achieve Complete Resection of Difficult Colon Polyps

908 Avulsion: a Novel Technique to Achieve Complete Resection of Difficult Colon Polyps

Endoscopic Removal of Large and Difficult Colon Polyps

Videos are presented showing the technique of endoscopic mucosal resection (EMR) of large and difficult polyps carried out by the authors at their center, which is also a referral center for EMR of large and flat polyps, difficult polyps, and partially removed polyps. Most of the procedures are done in an outpatient setting under monitored sedation. The center has a large database of polyps removed by EMR. Its faculties are active in EMR-related research and have many recent publications in this area. The purpose of this instructional video is to teach EMR of large and difficult polyps to gastroenterologists. This article is part of an expert video encyclopedia.