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Endoscopic Management of Large, Flat Colorectal Polyps Current Trends in the Practice of Medicine Vol. 27 No. 6, 2011 Endoscopic Management of Large, Flat Colorectal Polyps INSIDE THIS ISSUE Large sessile polyps and flat colorectal lesions greater than 3 cm may occur in as many as 5% Points to Remember of adults undergoing colonoscopy. Historically 2 Treatment Options for difficult to detect and remove, such lesions are • Once surgically managed, large, flat Benign Uterine Fibroids of particular concern because they pose a high colorectal polyps are now safely and risk of malignancy, especially on the right side effectively treated endoscopically—most of the colon. commonly with endoscopic mucosal 5 Pituitary Tumors: Team As recently as 5 years ago, most large polyps resection. Approach Advantages were managed surgically. But according to gastroenterologists at Mayo Clinic in Jackson- • Various endoscopes and snares enable ville, Florida, many of these lesions are now treatment of polyps in any part of the 6 Titanium Plates successfullyA treated using endoscopic methods gastrointestinal tract accessible to endos- Stabilize Broken Ribs (Figure 1). Advances in both imaging technology copy, including the esophagus, stomach, and treatment methods have paved the way for and duodenum. endoscopic management of difficult polyps. Chromoendoscopy allows for better identi- • Endoscopic submucosal dissection, a fication of lesions as well as better endoscopic technically demanding procedure that characterization. And the variety of endoscopes allows for en bloc resection, is gaining acceptance in a few large US centers. and snares available today make it possible to treat polyps in any part of the gastrointestinal tract accessible to endoscopy, including the esophagus, stomach, and duodenum. Endoscopic Mucosal Resection Today, endoscopic mucosal resection (EMR) is the treatment of choice for large, flat, and sessile colorectal lesions (Figure 2). It may be performed using electrocautery or cold snare excision, with or without lifting agents such as saline and hydroxypropyl methylcellulose. Lifting agents create a cushion between the base of the polyp and healthy tissue, making removal easier and reducing the risk of perfora- Figure 1. Normal polyps traditionally have been removed tion. Mayo Clinic researchers are currently doing endoscopically. Large, flat polyps have not. studies comparing snares and injectates to see whether a particular combination facilitates better removal. Bleeding is the most common complication of EMR, occurring in about 6% to 8% of cases in the colon and in 11% to 17% in the duodenum. Generally, bleeding can be well controlled with forceps and coagulation grasping, argon plasma coagulation, or endoscopic clipping. Perforation is a second major complication but, in experi- enced hands, tends to occur in less than 5% of patients. Follow-up to check for recurrence and residual disease is recommended 3 to 5 months after the procedure. Residual disease, which can occur in 8% to 17% of patients, is often success- fully treated with repeat EMR. Figure 2. Endoscopic mucosal resection is a safe and definitive technique for removing large, flat Endoscopic Submucosal Dissection polyps in the gastrointestinal tract. Endoscopic submucosal dissection (ESD) is another recent advance in endoscopic therapy. ESD is performed by physicians well trained in Used in Japan and, increasingly, in a few large the procedure. In Japan, ESD is used to remove centers in the United States, ESD was developed nearly half of early gastrointestinal cancers. to aid en bloc resection, which both reduces Mayo Clinic endoscopists sometimes provide residual disease and allows for precise patho- close and meticulous observation in cases where logic evaluation. ESD requires great technical incidental findings are well contained and not skill and is much more arduous and time- penetrating. But patients whose lesions appear consuming than EMR. After injection of fluid cancerous are typically referred to surgeons. into the submucosal layer, the lesion is slowly The widespread use of EMR and, to a much and carefully removed from the base with an lesser extent, ESD has greatly reduced the endosurgical knife. number of colorectal lesions requiring surgery. The rate of complications such as bleed- EMR, in particular, has proved to be a safe and ing and perforation also may be higher with often definitive therapy for large, flat polyps in ESD than with EMR. At Mayo Clinic in Florida, the gastrointestinal tract. Treatment Options for Benign Uterine Fibroids Uterine fibroids affect up to 70% to 80% of women, and about 30% of women are symp- Points to Remember tomatic. Up to 75% of African American women have fibroids. More than 200,000 hysterectomies • Multiple treatment options are available are performed each year for uterine fibroids in for women who seek relief from heavy the United States. The direct health care costs bleeding and other symptoms related to attributable to this condition exceed $2.1 billion uterine fibroids. annually. Many fibroids can be felt on pelvic examina- • Hysterectomy offers permanent symp- tion. Ultrasound can detect those that are silent. tom relief for women who are not Not all fibroids require treatment, but many do. interested in future pregnancies. Symptoms include heavy or prolonged men- strual bleeding, anemia, pelvic pressure, pain • Less invasive treatment options can offer with menses, and bowel and bladder dysfunc- symptom relief and speedier recovery. tion. Asking patients about the severity of their These include medications, myomec- symptoms, whether their symptoms interfere tomy, uterine artery embolization, and with work or daily activities, or if they have new magnetic resonance–guided focused symptoms can help determine if fibroid treat- ultrasound therapy ment is necessary. 2 MAYO CLINIC | ClinicalUpdate Hysterectomy Fibroid Hysterectomy is a proven option for women who are not interested in future pregnancy Uterus and want to eliminate fibroid-related problems Embolic permanently. Hysterectomy is also a good choice agents Uterine for women with concerns such as abnormal Pap artery tests that require intensive follow-up, adeno- myosis, or endometriosis. In addition, surgery may have an impact on physical and emotional well-being, fertility, and sexual function. Other Treatment Options Today, multiple medical therapies and less inva- Catheter sive surgical approaches provide symptom relief, shorter hospital stays, and speedier recovery than hysterectomy. And some options preserve fertility for women who want to become preg- nant in the future. Listed below are some of the more commonly prescribed treatments. Figure 1. During UAE, a catheter emits embolic agents into the uterine artery. The embolic agents Medications then lodge in the uterine arteries and block the blood Various medications are now available to treat supply to the fibroids. fibroid symptoms such as heavy menstrual bleeding and pelvic pressure. These include oral contraceptives, gonadotropin-releasing hormone agonists, a progesterone-releasing Mayo Clinic Recruiting intrauterine device, and a new nonhormonal Participants for Research drug product called tranexamic acid. These Comparing UAE and MRgFUS medications offer some symptom relief, but they do not eliminate fibroids. Mayo Clinic researchers in Rochester, Min- nesota, are conducting a randomized clinical Myomectomy trial funded by the National Institutes of Health Myomectomy is an effective surgical option for (NIH) called the FIRSTT (Fibroid Interventions the removal of fibroids with preservation of the Reducing Symptoms Today and Tomorrow) uterus. This approach can relieve symptoms study. FIRSTT is the first large-scale randomized related to fibroid bulk and bleeding without sac- study designed to compare the effectiveness of rificing fertility. Although an abdominal incision UAE and MRgFUS in treating fibroids. The study is sometimes required for very large or numer- will follow participants for a total of 3 years after ous fibroids, many fibroids can be removed treatment to observe and compare symptom hysteroscopically or through just a few small relief, length of recovery, and any problems incisions using a laparoscope or robot-assisted associated with each of these treatments. Mayo approach to speed patients’ recovery and return Clinic researchers are still recruiting study par- to work. ticipants and are hopeful that the results will help Abdominal myomectomy usually requires a in the development of evidence-based guidelines hospital stay of 2 or 3 days, and postoperative for each of the available treatment options. recovery takes 4 to 6 weeks. Laparoscopic or Participants must be at least 25 years old and robot-assisted myomectomy is often performed not actively trying to become pregnant. Their with no hospital stay, and recovery typically uterus should be less than the size of a 5-month takes a few days to 2 weeks. Hysteroscopic pregnancy, and they must be able to undergo myomectomy is usually performed with no MRI. Women are not eligible if they have had a hospital stay, and recovery typically takes less major surgical procedure for their fibroids or prior than a week. The majority of women experience UAE or FUS. Most importantly, women must feel symptom relief, but new fibroids can develop both UAE and FUS are good treatment options. that may or may not require treatment. For more information or to refer a patient to Uterine Artery Embolization participate in the FIRSTT study, contact Lisa G. Larger fibroids can also be effectively
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