COMMENTARY

Techniques for Difficult Polypectomy

Douglas B. Nelson, MD

Disclosures

October 25, 2004

In This Article

Introduction

This discussion aims to provide the practicing gastroenterologist with additional techniques to facilitate the difficult polypectomy. However, this raises the question of what exactly constitutes a difficult polyp? One center reported its experience with patients referred for colectomy with a polyp believed to be too difficult to be removed endoscopically.[1] Prior to surgery, the patients underwent colonoscopy by highly skilled endoscopists, and endoscopic polypectomy was successful in 74% of cases. Another center found that specialist endoscopists attempted to treat endoscopically a greater proportion of large polyps -- which are often referred directly for operation -- with a higher ultimate completion rate, fewer referrals to surgery, and at less overall cost than their nonspecialist counterparts.[2]

Although at professional meetings it is always impressive to watch an expert demonstrate his technique of removing extremely difficult lesions, does this suggest that every endoscopist should attempt to remove every polyp? This is probably the wrong message to send. Large polyps are in fact associated with a higher rate of complications. Some polyps will require surgical removal, but the best gauge of whether a given endoscopist should attempt removal is the degree of experience and level of comfort of that endoscopist. However, as illustrated above, one should not assume that because one's own level of comfort is exceeded, that this necessarily mandates surgery; in such cases, the endoscopist should be willing to consult with a more experienced colleague or consider referring the patient to another center.

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