TOPIC OF THE MONTH Pediatric Colonoscopic Polypectomy Technique Marsha Kay and Robert Wyllie ABSTRACT (1–4). In adults, early cancer detection or cancer prevention in Colonoscopy with polypectomy is frequently performed in pediatric patients patients with nonmalignant but dysplastic polyps is the focus of based on symptoms, with the majority of polyps identified being benign polypectomy resection and ablation techniques. Therefore, the juvenile pedunculated polyps with a vascular stalk. This is in distinction to goal is a complete and by extension deeper resection to adults where polypectomy is often performed as part of a colon cancer limit the possibility of residual adenomatous tissue or of a 02/25/2020 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3be73+7zLk/Sq+y6koaZl6Ep8oGuop87+8AoBvh7J400mYizg71tReg== by https://journals.lww.com/jpgn from Downloaded Downloaded screening and prevention strategy and a higher fraction of polyps are sessile missed carcinoma. and or dysplastic. In adults, polypectomy techniques emphasize a need for In distinction, the majority of polyps in the pediatric popu- deeper resection to ensure complete resection of adenomas or potential from lation are simple juvenile polyps and have no premalignant poten- carcinoma in situ. Adenomatous polyps can occur in the pediatric age group https://journals.lww.com/jpgn tial unless occurring as part of a polyposis syndrome. The majority and may be associated with an underlying polyposis, hereditary or chronic are pedunculated with a moderate-to-long stalk and removal is inflammatory conditions. Polypectomy techniques include use of cold performed largely as the polyps are causing symptoms, such as biopsy forceps for very small polyps, cold snare polypectomy for small rectal bleeding, iron deficiency anemia or potentially intussuscep- sessile polyps and hot snare polypectomy for the majority of polyps in the tion. Mucosa adjacent to the juvenile polyp may have a character- pediatric age group. Adjuvant techniques include epinephrine volume by istic appearance known as ‘‘chicken skin mucosa,’’ resulting from BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3be73+7zLk/Sq+y6koaZl6Ep8oGuop87+8AoBvh7J400mYizg71tReg== reduction, saline-assisted polypectomy and hemostatic techniques including the presence of mucosal lipid-laden macrophages (5). An increasing injection, clip application and loop application to prevent or treat post- fraction of pediatric patients are identified to have more than 1 polypectomy bleeding. Electrosurgical principles guide the settings and type polyp at the time of full colonoscopy and patients with polyposis of current utilized during hot snare polypectomy. Polypectomy utilizing syndromes, such as Juvenile Polyposis Coli (JPC) may have a large thermal techniques is associated with a higher risk of complications com- number of polyps identified at the time of colonoscopy (6). pared with diagnostic colonoscopy. Adenomas have been identified in pediatric patients and are Key Words: colonoscopy, complication, electrosurgery, epinephrine associated with a higher risk of subsequent colon cancer develop- volume reduction, gastrointestinal bleeding, pediatric ment, and therefore, polyps removed at colonoscopy in the pediat- ric age group should be submitted for histologic evaluation to (JPGN 2020;70: 280–284) determine if patients need to enter more rigorous screening pro- tocols and potentially undergo genetic evaluation for FAP, HNPCC or other conditions. RATIONALE FOR PROCEDURE POLYPECTOMY TECHNIQUE olypectomy in adults frequently is performed as part of a Before polypectomy or any type of electrosurgery, the strategy to reduce the incidence of colon cancer based on the patient must be cleansed of fecal debris. A poorly prepared colon assumptionP that in the average risk adult population colon cancers limits visualization and increases the technical difficulty of the often arise from preexisting adenomas or neoplastic polyps. procedure. Excessive fecal debris or the use of certain gavage Patients in higher risk groups will require earlier or more frequent solutions, such as mannitol places the patient at risk for explosion screening and possibly additional intraprocedural imaging, such as during attempted thermal polypectomy (7,8). The patient’s risk of utilization of chromoendoscopy. These groups include those with a bleeding should be assessed by history, and blood work if indicated family or personal history of colon cancer, and those who have an including a complete blood count, coagulation profile, and if underlying disease process that makes them more susceptible to the necessary, blood typing. For patients on antithrombotics including development of cancer, such as IBD, familial adenomatous poly- anticoagulants and antiplatelet agents, modification of their anti- posis (FAP), or hereditary nonpolyposis colon cancer (HNPCC) thrombotic regimen in consultation with the patient’s care team and in accordance with current guidelines may be required as poly- Received May 27, 2018; accepted October 26, 2019. pectomy is considered a high risk for bleeding procedure (9). on From the Department of Pediatric Gastroenterology and Nutrition, Diminutive polyps of 3 mm or less in diameter are typically 02/25/2020 Cleveland Clinic Children’s, Cleveland, OH. removed with biopsy forceps or alternatively cold snare technique. Address correspondence and reprint requests to Marsha Kay, MD, Chair, Cold snare technique can also be used for slightly larger sessile Department of Pediatric Gastroenterology and Nutrition, Director polyps up to about 5–7 mm (10–13). Use of hot biopsy forceps, Pediatric Endoscopy, Cleveland Clinic Children’s, 9500 Euclid popular in the past, is now recognized to be associated with a higher Avenue, Cleveland, OH 44195 (e-mail: [email protected]). rate of procedure complications including significant bleeding and This article has been developed as a Journal CME Activity by NASPGHAN. perforation and is currently not recommended (11,14). Although Visit http://www.naspghan.org/content/59/en/Continuing-Medical-Educa described more than 20 years ago, cold snare technique is increas- tion-CME toview instructions, documentation, and the complete necessary steps to receive CME credit for reading this article. ingly utilized in adults for small diminutive sessile polyps and may The authors report no conflicts of interest. be associated with a more superficial resection depth versus hot Copyright # 2020 by European Society for Pediatric Gastroenterology, snare technique (10,15). Tenting of the polyp is not performed when Hepatology, and Nutrition and North American Society for Pediatric using a cold snare technique and gentle pressure is applied to the Gastroenterology, Hepatology, and Nutrition snare tip to anchor it to the colonic mucosa typically a few DOI: 10.1097/MPG.0000000000002591 millimeters distal (downstream) to the polyp to allow for resection 280 JPGN Volume 70, Number 3, March 2020 Copyright © ESPGHAN and NASPGHAN. All rights reserved. JPGN Volume 70, Number 3, March 2020 Pediatric Colonoscopic Polypectomy Technique of a small rim of surrounding normal mucosa in the case of target tissue and then courses through the path of least resistance adenomas (16). Aspiration of air during cold snare polypectomy to the neutral electrode (previously called the grounding pad) and is also not performed in order to avoid an inadvertent deeper then back to the electrosurgical unit. The minimal channel diam- submucosal resection. Snare closure when performing this tech- eter for current polypectomy snares is 2.8 mm; therefore, the nique is continuous until the polyp is guillotined utilizing a gentle current minimum endoscope outer diameter for polypectomy is ‘‘push and cut’’ technique compared with the ‘‘lift and cut’’ in the range of 9.0 mm. The snare is inserted into the endoscope technique used with hot snares (11,12). Dedicated cold snares with with the wire loop retracted. The endoscope tip should be stabi- different physical characteristics including a thinner and stiffer wire lized before advancing the polypectomy snare. The polyp, is compared with standard snares utilized for electrocautery and optimally positioned in the 5–7 o’clock position (17). This posi- which lack a connection for electrocoagulation have been devel- tion corresponds to where the snare or other instruments exit the oped and may assist in reducing the rate of stalling during polyp colonoscope at the 5 o’clock position. After appropriate position- transection (10,11) (Fig. 1). Polyps still require retrieval for histo- ing of the polypectomy catheter or sheath, only the amount of logic analysis. Cold snare technique has not been studied in snare necessary fully to encompass the polyp should be extended. pediatric patients to date. The polyp is then lassoed and the sheath maneuvered to the stalk. Large polyps (more than 5–7 mm in diameter) are usually The endoscopist should ensure that the snare encompasses only removed with snare electrocautery, especially juvenile polyps, the polyp head and stalk, and that normal bowel is not trapped which tend to be very vascular. This is a monopolar technique, within the snare to avoid deep thermal injury or perforation. where the current passes from the active electrode (snare) to the Polyps in a dependent position may be more difficult to access, and therefore, in some cases, the endoscope (or rarely if necessary the patient), and by extension, the polyp can be rotated to a more favorable position