A Review of the 2017 European Society of Gastrointestinal Endoscopy Guideline for Polypectomy and Endoscopic Mucosal Resection

Jung Ho Bae; Dong-Hoon Yang

doi:10.4166/kjg.2018.72.3.116

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Bae and Yang: A Review of the 2017 European Society of Gastrointestinal Endoscopy Guideline for Polypectomy and Endoscopic Mucosal Resection

Brief Summary of Practice Guideline

Korean J Gastroenterol 2018;72(3):116-120.

Published online: 4 October 2018

DOI: https://doi.org/10.4166/kjg.2018.72.3.116

A Review of the 2017 European Society of Gastrointestinal Endoscopy Guideline for Polypectomy and Endoscopic Mucosal Resection

Jung Ho Bae, Dong-Hoon Yang¹

Department of Gastroenterology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea

¹Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Correspondence to: Dong-Hoon Yang, Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. Tel: +82-2-3010-5809, Fax: +82-2-3010-6517, E-mail: dhyang@amc.seoul.kr, ORCID: https://orcid.org/0000-0001-7756-2704

Received 21 August 2018 Revised 23 August 2018 Accepted 23 August 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Endoscopic resection has been shown to reduce incidence and mortality of colorectal cancer. Endoscopic management has become an established therapeutic option for colorectal neoplasia, and therefore, polypectomy is among the most important colonoscopy skills to develop. An endoscopist performing polypectomy, such as cold snare polypectomy, hot snare polypectomy, and endoscopic mucosal resection (EMR), should be knowledgeable and skilled in selecting and performing the proper endoscopic technique to ensure curability and safety. Here, we report and summarize the key recommendations made in the recent guideline for polypectomy and EMR developed by European Society of Gastrointestinal Endoscopy.

Keywords: Guideline, Polyps, Endoscopic mucosal resection

References

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Table 1.

ESGE Main Recommendations for Colorectal Polypectomy and Endoscopic Mucosal Resection

Statements	Evidence	Recommendation
1. ESGE recommends CSP as the preferred technique for removal of diminutive polyps (size ≤5 mm). This technique has high rates of complete resection, adequate tissue sampling for histology, and low complication rates.	High	Strong
2. ESGE suggests CSP for sessile polyps 6–9 mm in size because of its superior safety profile, although evidence comparing efficacy with HSP is lacking.	Moderate	Weak
3. ESGE suggests HSP (with or without submucosal injection) for removal of sessile polyps 10–19 mm in size. In most cases deep thermal injury is a potential risk and thus submucosal injection prior to HSP should be considered.	Low	Strong
4. ESGE recommends HSP for pedunculated polyps. To prevent bleeding in pedunculated colorectal polyps with head ≥20 mm or a stalk ≥10 mm in diameter, ESGE recommends pretreatment of the stalk with injection of dilute adrenaline and/or mechanical hemostasis.	Moderate	Strong
5. ESGE recommends that the goals of EMR are to achieve a completely snare-resected lesion in the safest minimum number of pieces, with adequate margins and without need for adjunctive ablative techniques.	Low	Strong
6. ESGE recommends careful lesion assessment prior to EMR to identify features suggestive of poor outcome. Features associated with incomplete resection or recurrence include lesion size >40 mm, ileocecal valve location, prior failed attempts at resection, and SMSA level ^a 4.	Moderate	Strong
7. For intraprocedural bleeding, ESGE recommends endoscopic coagulation (snare-tip soft coagulation or coagulating forceps) or mechanical therapy, with or without the combined use of dilute adrenaline injection.	Low	Strong

Level of evidence and strength of recommendation were made by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

ESGE, European Society of Gastrointestinal Endoscopy; CSP, cold snare polypectomy; HSP, hot snare polypectomy; EMR, endoscopic mucosal resection; SMSA, size, morphology, site, access.

^a SMSA level: SMSA 1, 4–5 points; SMSA 2, 6–9 points; SMSA 3, 10–12 points; SMSA 4, >12 points.

Table 2.

The SMSA Score and Level ^a for Determining the Complexity of Polypectomy and EMR

Size	Points	Morphology	Points	Site	Points	Access	Points
<1 cm	1	Pedunculated	1	Left colon	1	Easy	1
1–1.9 cm	3	Sessile	2	Right colon	2	Difficult	2
2–2.9 cm	5	Flat	3
3–3.9 cm	7
>4 cm	9

SMSA, size, morphology, site, access; EMR, endoscopic mucosal resection.

^a SMSA level: SMSA 1, 4–5 points; SMSA 2, 6–9 points; SMSA 3, 10–12 points; SMSA 4, >12 points.

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ORCID iDs: Dong-Hoon Yang
https://orcid.org/0000-0001-7756-2704
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