Colonoscopy for colon polyps. Endoscopic removal - technique. Polyps in the intestine: signs, symptoms, treatment in adults How to remove a polyp from the dome of the caecum

A polyp of the caecum is a benign neoplasm, most often localized in the lower and widest section. Visually, polyps resemble cauliflower caps and have an oval head and base. The tumor consists of cells of the mucous membrane of this organ.

The caecum is part of the department small intestine. It has a length of about 10 centimeters, a width of up to 9 centimeters (lower part). The intestine is on the right, which means that the symptoms will appear from this side.

Polyps in the caecum are dangerous in that serious complications develop and the possibility of transformation into malignant tumor.

When making a diagnosis, it is necessary to conduct an accurate diagnosis. A timely diagnosis facilitates treatment and helps in preventing the development of complications.

1. Colonoscopy is a method that allows you to carefully examine the inside of the intestine, as a result of which it is possible to assess its condition. During this procedure, you can take a biopsy material or remove any growths. The procedure is performed endoscopically and allows you to examine the body along its entire length.
2. Sigmoidoscopy is performed using a device such as a rectoscope. At its end there is a lighting device and a camera. With this method, a detailed examination of the intestine is possible.
3. Irrigoscopy is one of the types of diagnostics using X-rays. For a reliable result, a contrast agent must be used.
4. Fecal analysis is necessary to determine the presence / absence of occult blood in stool ah, however this is not a common symptom this disease blind gut.
5. A biopsy is an analysis necessary to determine the etiology of the tumor, whether it is malignant.

• CT scan;
• Magnetic resonance imaging.

Such research methods do not require preliminary preparation and do not bring discomfort during the procedure, most accurately indicate the location of the neoplasms and their number. The disadvantage is the impossibility of taking material for histological examination.

It is necessary to undergo preventive diagnostics at least once every 3-4 years. When a disease is detected in early stages treatment success is over 90%.

Polyps, as a rule, do not give specific symptoms in order to pay attention to them in a timely manner and identify the disease in the initial stages.

• the size of the polyp;
• localization;
• the number of polyps;
• presence of oncology.

Patients suffering from this disease often complain of aching pain, bloating, the presence of blood streaks in the stool and constipation. When probing, the organ is dense. Appetite may not decrease, but body weight decreases sharply, manifestations of rapid fatigue of the body develop. If the polyp has a small size, the clinic is not expressed in any way, but if the size is large, then a symptom such as obstruction appears. Polyps, which are impressive in size, can penetrate the wall of the cecum (perforate), because of this, such a complication as bleeding occurs. With constant blood loss, anemia occurs. Patients may also complain of nausea, a feeling of fullness in the stomach, or belching.

Pay attention to even minor dysfunctions gastrointestinal tract, these may be harbingers serious illnesses polyps of the caecum or oncology of the intestine.

To date, it has been clear a large number of reasons for the formation of polyps, they are largely related to the environmental problems of the population and the wrong way of life:

• Inflammatory processes of the intestinal walls, which are chronic. With inflammation, the integrity of the intestinal mucosa is violated, and this contributes to the formation of polyps. Constipation and irritable bowel syndrome can provoke the appearance of neoplasms. Often, polyps are located in the place of stagnation of feces or violations of the integrity of the mucous membrane of the caecum.
• Often the factors leading to the disease in question are alcohol consumption, smoking, food containing chemicals (dry snacks and lack of a meal schedule), an immobile lifestyle, environmental pollution.
• genetic predisposition. There are cases of polyp formation in the absence of diseases or risk factors (mainly in young children).
• Violation of intrauterine development of the intestine, the theory of the embryonic occurrence of polyps (it is believed that if the intrauterine formation of the intestinal mucosa is disturbed, there is a predisposition to their appearance).
• Pathologies of the digestive system (varicose veins internal organs; intestinal ischemia resulting from blockage of the abdominal aorta).
• food allergy.
• Gluten intolerance (when it enters the body, the immune system tries to get rid of it, which as a result leads to injuries of the mucous membrane).
• Age over 40 years (in men after forty years this pathology occurs more frequently than in women. The total incidence of this population group is about 9-10%).
• The theory of the embryonic occurrence of polyps (it is believed that if the intrauterine formation of the intestinal mucosa is disturbed, there is a predisposition to their appearance).

If you have problems with the intestines, you need to contact a specialist for diagnosis and correct diagnosis. If the patient is subject to risk factors for the development of the disease, then do not forget about the need for an annual check-up.

The degeneration of polyps into a malignant tumor is a frequent process, occurring in 70-75% of all cases. Factors on which it depends: the type of polyp and its size.

• tubular (glandular);
• villous;
• glandular-villous.

Glandular adenomas are least prone to the process of malignancy, and villous - to rebirth. The size of the polyps also affects this process: the larger it is, the higher the likelihood of oncology.

It is for these reasons that it is necessary to remove polyps, even the smallest sizes.

With a disease such as polyposis, at the moment there are no methods conservative treatment. All types of polyps are subject to surgical intervention. When examining the intestine with an endoscope, it is sometimes possible to remove a polyp if its size and localization allow.

During colonoscopy, small polyps can be removed by clamping the base with an electrode (electroexcision). When removing the neoplasm, perforation of the intestine, complicated by bleeding, may occur. After surgery, adenomas are sent for histological analysis to determine the nature (benign, malignant). If oncology is confirmed, the entire section of the intestine is subject to removal.

After the removal of polyps, there is a huge risk of recurrence of the disease. To avoid this, it is necessary to undergo examinations: after one year - a colonoscopy, and then every 4-5 years.

If polyps of the caecum are found, it is necessary to immediately resort to surgical intervention, there is no alternative method of treatment.

With normal bowel function, mucosal cells are constantly updated. In case of failures, hypertrophic proliferation of cells occurs.

Neoplasms of tumor etiology appear in the form of fleshy growths called polyps. Usually they are benign in nature, but over time they can transform into malignant tumors.

Features of formations

Polyps of the rectum are diverse in their external characteristics. In the digestive tract, movable polyps are isolated with a stalk mount, creeping - on a wide base, single and multiple growths in nests.

In shape, oval, spherical, mushroom-shaped, papillary, villous formations are distinguished.

The color varies from pink to deep burgundy. Often yellow and gray growths. The color depends on the quality of the connective tissue and its quantity, passing vessels and structure.

Fibrous tissue makes the structure more dense, with a predominance of glandular tissue, the structure of the growth is soft. The surface of the neoplasms can be smooth and bumpy.

Characteristic differences from hemorrhoids

On the surface of the tissues of polyps, the process of erosion can begin. Erosion leads to bleeding from the anal canal,

In the photo, a polyp located in the rectum

The symptoms of these diseases are similar, but they are fundamentally different in etiology, development and treatment methods. Localization of polyps in the rectum occurs at the anus. The overgrown tissues of the neoplasms fill the intestinal lumen and may protrude into the anus.

Hemorrhoids are inflammation followed from the anus due to stagnation of blood in the vessels of the pelvic organs. Hemorrhoids are accompanied painful sensations and thrombosis.

Neoplasms rarely fall out of the anal canal, but if this happens, distinguish the polyp and hemorrhoid Only a doctor can with an adequate diagnosis.

There is also the possibility of an outgrowth on hemorrhoids, especially in cases where the disease flows into.

Species and structural classification

The main danger of polyps in the rectum is their possible degeneration into a malignant tumor. Such a transformation is called malignancy. The larger the neoplasm, the higher the risk of its malignancy.

The degeneration of a neoplasm also depends on the tissue from which it originates. Conventionally, all polyps are divided into two groups depending on the degree of possible degeneration.

The first group with a minimal probability of transformation into a malignant tumor is fibrous polyps, in turn they are:

1. Inflammatory formed in the rectum due to past gastrointestinal diseases and intestinal infections. They are not large, often they are convex thickening of the rectal wall. The probability of malignancy is minimal, concomitant dysplasia (pathology of development and formation) of connective tissue can become a risk factor. As a rule, dysplasia is a congenital disease, due to a genetic predisposition.
2. Hyperplastic usually do not exceed four millimeters, have a conical shape. When affected by hyperplastic intestinal polyps, there is a possibility of their growth, but, despite the number, they do not transform into a malignant formation.
3. Juvenile observed in children and adolescents, are cluster-shaped and have a smooth surface, often resolve without any effect, do not transform, although in some cases they can grow. Development risk factor oncological disease- congenital dysplasia.

Fibrous polyps of all kinds are usually called pseudotumors because of the minimal likelihood of their malignancy. Although according to appearance they look like polyps of the second group, which are life-threatening.

The second group includes adenomatous polyps of the following types:

1. villous- the most common type of adenomatous neoplasms. characteristic feature- the absence of a leg or its significant shortening, similar in shape to a cauliflower. There is a subspecies of villous polyps, which grows like a carpet, in this case the tumor node is not observed. In more than 90% of cases, villous growths transform into a malignant formation.
2. glandular can have a structure with a leg and without it. A size of less than two centimeters is considered safe, but with an increase in the glandular polyp, the probable degeneration reaches 50%. There is also a mixed species - glandular-villous. Differs in a lobed structure with a large number of villi. Also applies to adenomatous polyps with a high probability of malignancy.

It must be noted that such a classification is actually conditional. And experts believe that fibrous polyps, which rarely develop into a malignant tumor, can be no less dangerous than adenomatous ones.

A polyp of any group and species can be transformed with untimely or inadequate treatment, the difference will be in the timing of the transformation. For the degeneration of a villous adenomatous polyp, experts give a period of no more than five years, while for a hyperplastic fibrous polyp - about fifteen.

Risk factors and causes of growths

The formation of polyps contributes to the violation of the regenerative function of tissues. But the exact causes of regenerative dysfunction are still difficult to voice, and scientists can only make assumptions about this.

Risk factors include:

• genetic predisposition;
• pathology of intrauterine development;
• inflammatory processes in the intestines;
• disorders or eating habits;
• external negative impact;
• bad habits.

If polyposis was previously observed in the patient's family, then the probability of the appearance of neoplasms and their degeneration is at least 50%.

The connection between the appearance of polyps and pathologies of intrauterine development in the form of improperly formed intestinal walls of the fetus has been practically proven.

Inflammatory processes and infection in the intestines lead to the appearance of polyps, for example, diseases such as colitis, dysentery, enteritis. Unhealed hemorrhoids can also become a risk factor and provoke the formation of growths in the rectum.

Scientists have recorded a direct relationship between the appearance of polyposis and bad habits.

In patients suffering from nicotine and alcohol addiction, sharply increases the likelihood of formations and their malignancy.

Nutritional traditions are of no small importance - the use of animal fats in large quantities, the lack of products plant origin become the cause of the disease.

Negative external influence refers to an unfavorable environmental situation; residents of the metropolis are at risk. Polyposis can affect the elderly and children with an insufficient degree of activity.

Features of the clinical picture

Usually, during the first five years, polyps do not make themselves felt, their formation and growth may be asymptomatic.

And only with the increase in individual growths or extensive growths of group neoplasms does the first symptomatology appear.

The appearance of polyps in the rectum can be suspected by the following signs and symptoms:

• pathological discharge during defecation- there may be bleeding, and purulent discharge in case of infection, erosion and inflammation of the growths;
• - irritation, pain, sensation of a foreign object;
• stool disorders- diarrhea and constipation;
• negative sensations in the gastrointestinal tract- Flatulence, pain, sometimes radiating to the lower back, difficulty passing gases.

In complex conditions with polyposis, there is an increase in temperature and the loss of polyps during defecation. Any symptom is a reason for an urgent diagnosis of the digestive tract.

Diagnosis of violation

The likelihood of degeneration of polyps in the rectum into malignant tumors increases due to the asymptomatic development of the disease.

Therefore, early diagnosis is especially important.

In addition, the diagnosis excludes diseases similar in symptoms - hemorrhoids, swollen lymph nodes, intestinal diseases of infectious etiology.

Diagnostics is carried out by the following methods:

Goals and methods of therapy

Drug therapy as a method of treatment of neoplasms of the rectum is recognized as ineffective, so the surgical removal of polyps in the rectum is the main technique.

Removal can be complete - in the form abdominal surgery or endoscopic.

Surgical intervention is indicated for the degeneration of a polyp into a cancerous tumor, intestinal obstruction, enterocolitis and, the formation of cracks, the development of anemia.

Endoscopic Surgery

Endoscopic surgery is the least traumatic, as it allows you to remove polyps without incisions on the body.

Wherein general anesthesia not required, minimal blood loss, formation of adhesions, the rehabilitation period is significantly reduced compared to a full-fledged operation.

There are two techniques for removing polyps - by charring (cauterization) and excision.

Types of endoscopic intervention:

• electrocoagulation– impact of current on tissues and wound postoperative surface;
• transanal excision- the base of the polyp is excised, electrocoagulation is additionally used to char the wound surface and exclude extensive blood loss;
• electroexcision– excision with electric loops, the polyp is not only charred, but also removed, the advantages are minimal blood loss.

In case of malignancy of the formation, resection and colotomy are performed:

1. Resection- an operation in which part of the intestine is removed through the anus. Then the malignant formation is removed along with the affected nearby tissues and part of the rectum.
2. At colotomy an incision is made abdominal cavity, the intestine is pulled out, the part affected by polyps is removed. Both procedures are performed under general anesthesia.

What is the disease?

Neoplasms in the rectum are dangerous with the following problems:

Preventive measures

Prevention of polyps is the elimination of risk factors leading to their formation. Since the exact causes of the appearance of growths have not yet been established, in the form preventive measures lifestyle modification recommended bad habits and adherence to healthy eating habits.

It is necessary to systematically examine for the detection and treatment of inflammatory processes of the digestive tract. It is believed that in a healthy intestine, in the absence of a genetic predisposition, polyps cannot appear.

Therefore, early treatment the best prevention. Can lead to the formation of polyps chronic form colitis, enteritis, Crohn's disease.

It is necessary to eliminate the stagnation of feces. Deficiency of trace elements and vitamins also leads to the appearance of growths, so a balanced diet remains important and, as an additional measure, vitamin therapy.

1 SBEI HPE "Saratov State medical University them. IN AND. Razumovsky" Ministry of Health and Social Development of Russia, Saratov

The article is devoted to evaluating the effectiveness and features of endoscopic polypectomy for large villous adenomas of the colon using the clipping technique to avoid the risk of complications. The paper analyzes the results of applying the clipping technique when removing large villous colorectal polyps using a device for bringing and applying endoclips - a clip applicator and titanium clips from Olympus. The results of the work performed showed that the use of the clipping technique involves minimizing the risk of bleeding and the use of low-power coagulating current for a short period of time, while the risk of intestinal perforation is also minimal. For resection of large colorectal polyps, this technique has advantages over the conventional one and is the most promising for removing polyps through a colonoscope.

villous colorectal polyp

endoscopic adenomectomy

clipping

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3. Pantsyrev Yu.M., Gallinger Yu.I. Operative endoscopy of the gastrointestinal tract. – M.: Medicine, 1984. – 192 p.

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6. Fujisawa M7 Endoscopic resection of large colorectal polyps using a clipping method / Y. Iida, S. Miura, Y. Munemoto, Y. Kasahara, Y. Asada, D. Toya // Dis Colon Rectum. - 1994. - Vol. 37. – P. 179–180.

7. Rosen L., Bub D.S., Reed J.F. III, Nastasee S.A. Hemorrhage following colonoscopic polypectomy // Dis Colon Rectum. – Vol. 36. – P. 1126–1131.

8. Repici A., Tricerri R. Endoscopic polypectomy: techniques, complications and follow–up // Tech Coloproctol. - 2004. - Vol. 8. - Suppl 2. - P. 283-90.

Endoscopic polypectomy has now become the main treatment for benign and malignant colon polyps. It belongs to the category of surgical interventions and is accompanied by a certain risk of complications. Most dangerous complications are bleeding from the bed of the removed polyp or the remaining part of the leg and perforation of the intestinal wall. Complications of this nature, according to some authors, are 6-8% and may occur immediately after polypectomy or a few days after surgery.

The threat of bleeding and perforation is really very high if the polyp has a thick stalk or a wide base, with a large size of such a formation. These are self-evident things, since the more massive the tumor, the more intense its blood supply should be.

Improvement of endoscopic methods of polypectomy contributes to an increase in therapeutic efficacy and, consequently, an adequate choice of treatment methods and an increase in the number of justified, from an oncological point of view, endoscopic interventions.

Purpose of the study- to evaluate the effectiveness and features of endoscopic adenomectomy for large villous adenomas of the colon using the clipping technique to avoid the risk of complications.

Materials and methods of research

The generally accepted technique of polypectomy is associated with the risk of complications such as bleeding and perforation. Bleeding can occur when using insufficient, and perforation - excessive power electric current. Since the wall of the large intestine is much thinner than the wall of the stomach, the “safety zone” for polypectomy through a colonoscope will be less than when removing gastric polyps. We proposed a clipping technique for endoscopic removal of large colorectal polyps. In this case, special endoclips are applied to the base of the polyp, after which electrosurgical removal of the polyp is performed. The technique of applying brackets is very simple and is even easier to perform than a biopsy.

Endoclipping was performed using a device for bringing and applying endoclips - a clip applicator (НХ-5LR-1) from Olympus (Fig. 1) and titanium endoclips MD-59, MD-850 (Fig. 2).

As a generator of high-frequency electric current, a Surdi Star electrocoagulator (Valley lab) was used. The power of the coagulation current at normal voltage (110 V) ranged from 1.5 to 15 W. To remove colon polyps, a crescent-shaped loop electrode manufactured by NPO Medinstrument, Kazan, was used.

Rice. 1. Clip applicator HX-5LR-1 2. Endoclips

Research results and discussion

In the colonoscopy room of the Municipal Healthcare Institution "Gorodskaya clinical Hospital No. 8, we used the clipping technique to remove large villous colorectal polyps in 10 men and 7 women (a total of 17 patients), whose age ranged from 30 to 75 years (mean age 55 years). Polyps on a leg during or after removal have a tendency to bleed, since there are a large number of feeding vessels at the base of the polyps. Therefore, we used the clipping technique to remove these polyps, even if they were small.

In 10 cases, a nodular form of the tumor was detected, in 4 - creeping, in 3 - mixed. 8 (47%) large adenomas had a nodular form of growth with a pronounced exophytic component protruding significantly into the intestinal lumen, the largest dimensions of which in 5 cases ranged from 3.0 to 4.0 cm and in 3 cases - from 4.0 to 5. 5 cm Nodal shape the tumor was defined as a tumor node with a well-defined base, with a creeping form, the tumor spread over the surface of the mucous membrane, manifesting itself as villous or small-lobed growths. With a mixed form, a combination of signs characteristic of the nodular and creeping forms was noted. Large nodular adenomas were located on a wide and narrowed base, but more often had a short or long stalk. The largest adenomas were found in the rectum. Of the 7 epithelial neoplasms of various macroscopic shapes with a diameter of more than 5.0 cm, 4 (57%) were localized in the rectum, 3 of which spread to the anal canal, significantly complicating their endoscopic removal.

To identify ultrasound signs of malignant transformation of the villous tumor in 12 cases, we compared the results of pathomorphological examination and ultrasonographic data. As a result of this comparison, we can distinguish the following ultrasound signs of malignancy of a villous tumor:

1) violation of the five-layer structure of the intestinal wall;

2) pronounced echo heterogeneity of the tumor;

3) the presence of increased lymph nodes in pararectal tissue;

4) the presence of mucus in the intestinal lumen.

These signs allowed us to make a differential diagnosis of benign and malignant villous tumor in 93.3% of cases.

Localization, size and other macroscopic characteristics of large colon adenomas determine a number of tactical and technical features of endoscopic interventions.

For large and giant adenomas of the large intestine, we used the following methods of their endoscopic removal: single-stage loop electroexcision and fragmentation.

Simultaneous removal of the tumor with a loop electrode, in our opinion, is advisable only for nodular neoplasms with a diameter of not more than 4.0 cm, which have a long stem.

In all other cases, the simultaneous removal of large adenomas, even on a short stalk, is fraught with the development of complications. Therefore, regardless of the form of growth, when removing large adenomas, we used their fragmentary removal, which consists in successive capture with a diathermic loop and cutting off individual sections of the tumor until it is completely removed.

11 large adenomas of the large intestine were removed by single-stage endoscopic interventions; in 6 cases, the removal of neoplasms was performed in two stages. In 4 cases, multi-stage endoscopic interventions were planned due to very large adenomas.

Despite the considerable size of the removed adenomas, malignancy was detected only in 4 (20%) of them during morphological examination. This is, on the one hand, evidence that colon adenomas can reach gigantic sizes while remaining benign; on the other hand, it indicates the need for a more rigorous selection of neoplasms subject to endoscopic removal.

Our studies have shown that regenerative-reparative processes in the area of ​​endoscopic removal of large adenomas are completed no later than 3-4 months after endoscopic intervention. In general, the timing of epithelialization is variable and depends on the initial size of the wound defect and the depth of coagulation necrosis.

Evaluation of long-term results of treatment of patients with large colon adenomas using the clipping technique in terms of 1.5 to 5 years showed the high efficiency of endoscopic methods. After removal of larger adenomas, single or multiple endoscopic interventions were effective in 93% of patients. positive results Treatment failed in only 7% of cases. The reasons for the failures were persistent recurrence of adenomas (2.4% of cases), pronounced cicatricial strictures (2.4% of cases) and the development of cancer at the site of previously removed malignant adenomas (4.8% of cases).

None of our patients bled as a result of this polypectomy technique. In 42 patients, the removal of polyps was carried out according to the generally accepted method, as a result of which in 7 patients (17%) bleeding occurred during polypectomy and in 2 patients (5%) in the postoperative period.

Since the clipping technique assumes no bleeding and the use of a low-power coagulating current for a short period of time, no perforation occurred in any patient. Perforation and peritonitis occurred in one patient (2%) using the conventional polypectomy technique.

Since the endoclips are made of metal, cutting and coagulation becomes possible throughout the entire thickness of the tissue. Thus, the likelihood of perforation becomes significant only when the staples are applied too close to the intestinal wall and come into contact with the loop. The depth of capture of the paper clip is limited to the submucosal layer and there has not yet been a case of capture of the true muscle layer. In general, the development of any serious complications was not observed. There were also no complications associated with the use of endoclips.

Removal of large colon polyps using the clipping technique has the following features:

1) it is the most advanced polypectomy technique;

2) the base of the polyp is clamped with two or three staples, after which the color of the polyp acquires a characteristic cyanotic hue;

3) the imposition of the loop is carried out distal to the staples in relation to the intestinal wall;

4) then electrosurgical removal of the polyp is performed in the coagulation mode;

5) the clipping technique can be widely used in therapeutic colonoscopy to stop bleeding that has developed as a result of polyp removal according to the generally accepted technique.

conclusions

1. Using this technique, it is possible to carry out the simultaneous removal of large polyps en bloc, and not in parts. The presence or absence of carcinoma in the resection area is determined by the detection of carcinoma in the removed polyp. In this way, an unnecessary operation can be prevented.

2. Often it is impossible to determine the nature of the polyp (recurrent or new), which is found in the area of ​​the previous polypectomy. This is easy to determine if staples remain in the polypectomy area, which remained in place during the observation of the patient for 26 months. We believe that endoclips should be applied deep into the tissues to prevent their accidental falling off. In this case, paper clips can serve as a kind of marker.

3. Staples are radiopaque. If a minor colorectal lesion is detected endoscopically, and staples are applied close to it, then double-contrast barium enema can easily localize the lesion and achieve a high-quality x-ray image.

4. During surgical removal of colorectal lesions, it is often difficult to determine their localization during the operation. Even with transanal removal of rectal masses, it is often difficult to locate the lesion on intraoperative examination. If staples are applied before surgery, the localization of the lesion is easily determined by palpation or inspection, which eliminates the need for intraoperative colonoscopy. This is one of the advantages of the endoscopic clipping technique.

We came to the conclusion that the clipping technique for resection of large colorectal polyps has advantages over the conventional one and is the most promising for removing polyps through a colonoscope. It is advisable to equip all departments that deal with intraluminal endoscopic surgery with devices for applying clips.

Reviewer-

Chalyk Yu.V., Doctor of Medical Sciences, Professor, Professor of the Department general surgery Saratov State Medical University named after V.I. Razumovsky" of the Ministry of Health and Social Development of Russia, Saratov.

The work was received by the editors on December 26, 2011.

Bibliographic link

A polyp is a growth that appears when the mucous membrane is inflamed. They are oblong in shape, have contact with organs, with the help of a thin stem or a wide base.

Typical sites for polyps?

Theoretically, there is the possibility of their appearance in the space of the entire mucosa, however, the most typical place is the nose, paranasal sinuses, stomach and large intestine, bladder, cervix and body of the uterus, followed by the small and rectum, vagina.

What is the danger of polyps?

Based on their specific histological structure, there is a possibility of diagnosing a malignant, oncological, formation. Therefore, the need for their timely elimination is beyond doubt.

Varieties.

The polyp can be not only small, but also quite large. In addition, the polyp is divided into complicated, uncomplicated, single and multiple. There are various options in shape: spherical, fusiform, villous, smooth, lobed. Based on the specifics, the necessary path of treatment is selected.

How to remove polyps with endoscopy?

Removal of polyps occurs using the endoscopic method. The difference lies in the number of sessions: if there are few polyps, everything is removed at a time, but if there are many, you will have to visit the doctor again.

Removal of polyps that have appeared in the colon or rectum is also performed by the endoscopic method. This path is a wonderful analogue of intestinal resections, since in the latter case it is supposed to perform a rather difficult and traumatic surgical intervention, which can have great negative consequences. It is no coincidence that many doctors choose the endoscopic method, including if the patient has a tendency to relapse. Then you need to do a colonoscopy every year and with endoscopic polypectomy, radical surgical methods are resorted to only if the disease progresses, or malignant cells in the polyp have been detected. polyp removal process Bladder based on the endoscopic method, it is carried out using cystoscopy, and hyteroscopy is used in the uterine region.

Features of the technology for the removal of the polyp in the endoscopic method.

A necessary condition for the removal of a polyp is the presence in the endoscope of a special manipulator used for minimally invasive intervention. To date, 3 methods are practiced to remove a polyp using the endoscopic method:

. Cutting legs with very thin metal loops;

Excision of the polyp using the supplied electric current;

Conducting electrocoagulation with a biopsy forceps.

The use of the first option at this stage is very rare, due to the high likelihood of bleeding. Electric excision has become more widespread: after the leg of the polyp is pinched, an electric current is applied, which carries out preventive procedures and tissue cutting. As a result, polyps are removed, moreover, the latter can be further examined, since it is not damaged under the influence of current. However, this path is possible if the polyps are large, exceeding 5 mm. Otherwise, it remains to use electrocoagulation and biopsy forceps, which capture polyps and coagulate. As a result, the core of the polyps is not damaged and is also subject to careful analysis.

The specifics of the recovery period.

For the next two weeks, doctors recommend antibiotic therapy, then you should turn to the control procedures to check the condition of your body, based on which, a list of further preventive measures is compiled.

Polyps usually do not show any symptoms. Diarrhea causing loss of potassium is rare in villous adenomas. In neuroendocrine tumors of the direct or sigmoid colon, which usually have hormonal activity, clinical manifestations observed only when metastasis occurs in the liver. The only symptom in such cases is the appearance of blood in the stool. But already this symptom is enough to suspect a tumor or an intestinal polyp. With the exception of family syndromes manifested by intestinal polyposis, polyps in most cases are an accidental finding, including during preventive colonoscopies.

With polyps, there is no need to carry out differential diagnosis, since when a polyp is detected, it should be removed. To leave or excise small adenomas, to conduct or not to conduct a histological examination of removed tumors? To date, these issues are the subject of scientific discussions, but excision followed by histological examination operating drug. A special situation develops with a long-term course of nonspecific ulcerative colitis. In these cases, differentiating neoplastic polyps from pseudopolyps can be difficult, as well as sporadic adenoma from a tumor associated with chronic inflammatory process in the intestine.

Revealing polyps requires an immediate decision regarding their treatment. It was previously mentioned that small hyperplastic polyps in the rectum are a common finding and may be left. This does not exclude the formation of an adenoma in the rectum. Differential Diagnosis polyps detected in the upper rectum is not easy. Small hyperplastic polyps, unlike adenomas, are characterized by a fine-grained surface, which, when viewed under optical magnification, is dotted with numerous dimples.

With absence confidence that the identified formation is a harmless polyp, it should be removed. Multiple small whitish polypoid masses in the distal rectum are usually hyperplastic in nature and may be left.

In addition to the main question whether it is necessary to remove an adenoma endoscopically detected during colonoscopy, it is also important that the endoscopist master the removal technique. Perforation of the intestinal wall with insufficient skills from the doctor is only one side of the increased risk. Incomplete removal of a large adenoma represents a medium-term risk for the patient greater risk. The resulting scar makes it difficult to remove the residual adenoma during repeated intervention, and it is impossible to reliably prevent recurrence even with the use of argon plasma coagulation. When in doubt, the doctor should seek help from a more experienced colleague.
The updated guidelines DGVS"Colorektales Karzinom" also has information on the treatment of polyps.

polyps less than 5 mm in diameter can be removed with forceps. The probability that there are atypical cells in the removed polyp is extremely small. The only exceptions are very small flat or even depressed polyps (adenomas). You can determine the size of the polyp using forceps. The gap between the branches with open forceps ranges from 2 to 6 mm.

When removed polyp using forceps, even if it is small, it is important that it is full. A biopsy should not be performed. When removing a polyp, it is necessary to capture it with forceps along with macroscopically visible borders.

polyps with a diameter greater than 5 mm should be removed with a loop. There are a number of options for the loop, differing in size and shape. The choice of loop depends on the preferences of the endoscopist. This also applies to the use of a monofilament loop, which is preferred by some endoscopists, especially when removing flat adenomas. This loop is more rigid than its polyfilic braided counterparts and, in addition, provides a more precise effect (coagulation) on the tissue with an electric current. The dependence of the coagulating action of the loop on the shape of the electric current should also be taken into account. In some cases, depending on the material of which the loop is made, there is a risk of "cold" removal of the polyp. It also depends on the manipulations of the assistant, in particular on how much he tightens the loop. It should also be taken into account that the risk of perforation of the intestinal wall with a monofilament loop is also higher, since it cuts deeper into the tissue. However, there is no scientific or empirical evidence to support such a risk.

Regardless of the type loops usually a direct current is fed through it. The loop can be operated in coagulation and cutting mode, eg ENDO CUT (ERBE, Tübingen). By pressing the yellow pedal, a cutting current is applied, which in the initial phase, when the tissue resistance is still low, causes a soft coagulation. As the tissue dries, its electrical resistance rises, causing the voltage to rise until a light arc discharge occurs that is recognized by the system. The cutting phase lasts, depending on the system used in the apparatus, approximately 50 ms and is separated from the coagulation phase by approximately 750 ms. The cutting phase and the coagulation phase alternate until the polyp is removed. The setting of the ENDO CUT mode can in principle be changed, but in practice there is usually no reason to do so. For example, if it is necessary to enhance the coagulating effect, then they manipulate not the “Fast coagulation mode” knob, but mainly the “Effect” knob of the ENDO CUT mode. Turning the "Effect" knob to the "4" division means reducing the cutting current in favor of the coagulation current.

When removing small polyps the initial phase of the cutting mode (which parameters do not change) is important, since these polyps are usually cut off at the very first current pulses. During coagulation, the loop must be held parallel to the intestinal wall in order to better enclose the base of the polyp, which is important for effective tightening of the loop. It is necessary to “plant” the loop not too low, but not very high either, since in this case part of the polyp may remain unremoved. Particular care should be taken to remove polyps located in the fold of the mucous membrane. Having clasped the base of the polyp with a loop, it is pulled up and cut off. Small polyps, after cutting off, can be drawn into the working channel of the colonoscope. In this case, a filter (polyp trap) should be placed between the colonoscope tube and the suction hose. If there are no filters, you can use gauze folded in several layers, which is placed at the junction of the suction hose with the vacuum reservoir.

sucked polyps often obturate the working channel in the tube of the colonoscope. In such cases, it is recommended to inject 20 ml of water in the syringe under pressure through the rubber valve and at the same time close the suction valve. The resulting negative pressure is often sufficient to push the polyp out. Removal of pedunculated polyps is not particularly difficult, at least if the polyps are small. Next, we will consider in detail the technique of such interventions using the example of adenomas. With the help of high-resolution video endoscopy, it is possible to clearly identify the boundaries of the base of colon adenomas. The adenoma is cut off at the level of the basal third of its pedicle. Ideally, a pedunculated polyp can be grasped and removed.

polyps may appear intestinal bleeding. However, according to the macroscopic picture, it is impossible to judge what is the degree of risk of bleeding from a particular polyp. Prevention of bleeding, for example, by applying a Hamoclip clip or injecting a 1:10,000 dilution of epinephrine into the base of the polyp, is usually not required. When removing a polyp, small vessels should be carefully coagulated. There may be exceptions, such as when a polypectomy is performed on a patient taking acetylsalicylic acid. In some cases, depending on the morphological features of the removed adenoma, one or more clips are applied.

At removal very large pedunculated adenomas the risk of complications is particularly high. This is due, on the one hand, to the abundant blood supply to such an adenoma, on the other hand, to the use of high-frequency current. If, due to the significant density of the base of the polyp, it is impossible to securely apply clips before removing it, then the polyp is removed using the Endoloop loop. This loop remains in the intestine after application. The effect of the method can be judged immediately after such a loop is applied. The cessation of blood supply to the polyp leads to its cyanosis. When removing the polyp, you should pay attention to the fact that the wire loop, when applied, is above the hemostatic loop "Endoloop". The question of whether to impose a hemostatic loop or not, the doctor decides in each case individually. With a relatively short stem, the risk of intervention is due to the fact that the hemostatic loop can slip after cutting off the polyp. This can also happen some time after cutting off the polyp.

The risk of removal is also associated with the formation of bridges. They occur when the polyp touches the opposite wall of the colon. The current in such cases flows not only from the wire loop through the base of the polyp to the neutral electrode, but also through the polyp into the intestinal wall.

To avoid unwanted thermal effects polyp when removed, pull with a loop. If the volume of tissue covered by the wire loop is very large and the removal of the polyp takes too long, then excessive thermal effect can cause extensive destruction of the base of the polyp.

The macroscopic picture in adenoma is different diversity. In each case, it is necessary to have a clear idea of ​​the form of the adenoma before the intervention. This is facilitated by such manipulations as displacement of the adenoma with a colonoscope or some instrument, such as a tight wire loop, and insufflation of various volumes of air. It is especially important to clarify the localization of the adenoma relative to the folds of the mucous membrane. Often, adenomas, especially flat ones, turn out to be more extended than they seem at first glance.

When removing " pendulum» A polyp on a narrow base, located in a fold of the mucous membrane, an unexpectedly wide wound surface can form. Injection of the solution at the base of the polyp reduces the risk of perforation.

For removing polyp on a wide base, preference should be given to a monofilament loop. A correctly applied wire loop ensures precise tissue coagulation at an optimal level. The clarity of the edges of the mucous membrane allows you to find out if there is residual polyp tissue. If there is, then it should be removed using the same wire loop.

The thinnest wall of all parts of the colon, the caecum has, so the risk of its perforation is especially high. Even when removing small polyps formed in the caecum, one should resort to injecting a solution of sodium chloride into the base of the polyp. Such an injection not only reduces the risk of primary perforation of the intestinal wall, but also prevents extensive thermal tissue damage. A few drops of methylene blue are added to the injectable saline sodium chloride solution. It allows better identification of structures located under the mucosa and separated from it by the muscular plate, as well as identifying the residual tissue of the polyp.

For removing polyps on a wide stalk and villous adenoma, an injection into the base of a physiological solution of sodium chloride is recommended. Solution infiltration expands the submucosal space and facilitates separation from the muscularis mucosa. A few milliliters of methylene blue should be added to the solution, which greatly facilitates the examination of the base of the polyp and the assessment of the edges of the mucous membrane (the possibility of leaving residual adenoma tissue!). Minor bleeding from the wound surface can be stopped by injection of an adrenaline solution into the bleeding base of the polyp. It should be distinguished from an injection, which is given prophylactically and has not been shown to be effective. The injection can be repeated as needed. The polyp is removed in small pieces, being careful not to leave residual tissue. The remaining fragments are removed with forceps, capturing these fragments to the full depth of the branches. If the wound surface after cutting off the polyp is large, then Hamoclip clips can be applied; for a better fit of their ends, air should be sucked out of the intestine.

When removed polyp chunking (“piece by piece”), it doesn’t matter how many fragments it is divided into. You just have to make sure that these fragments are not too large. Removing the polyp in small pieces minimizes the risk of intestinal perforation.

Removal of villous adenoma carries the risk of not only perforation of the intestine and bleeding, but also the development of relapse when leaving the residual tissue of the polyp. It is difficult to remove recurrent polyps because of the scars formed after the first intervention. Therefore, after removing the polyp, it is necessary to carefully check wound surface and the edges of the mucosa to ensure there is no remaining polyp tissue. This task is facilitated by the use of high resolution endoscopes (image enhancement). The remnants of the polyp, detected when examining the wound surface and the edges of the mucous membrane, should be removed with a wire loop or forceps. When using argon plasma coagulation to treat the edges of the base of the polyp, the wound surface itself (muscular plate of the mucous membrane) should not be coagulated. Coagulation has been reported in the literature to reduce the risk of recurrence, but whether it should be preferred to removal of polyp remnants with forceps is not yet clear.

When describing large removal techniques, and especially flat, polyps after injection into the base of saline sodium chloride solution, the publication uses the concept of "mucosectomy". This is an endoscopic resection of the mucous membrane, which is often performed in the upper gastrointestinal tract, mainly with the help of a special nozzle on the endoscope (ligature mucosectomy). When applied to the colon, this intervention is called a polypectomy with hydraulic preparation; the name accepted in the English literature is Saline-assisted Polypectomy. Mucosectomy with a nozzle is performed mainly with damage to the rectum, since the more proximal sections of the intestine have a thin wall. Similarly, in submucosal dissection (endoscopic submucosal dissection), physiological saline is injected into the submucosa under the polyp and, stepping back from it at a certain distance, a bordering incision of the mucous membrane is performed with a knife. The latter is separated using the same knife from the deep layers of the submucosa. This method, in contrast to the one described above, takes more time and often causes complications, and if in diseases of the upper gastrointestinal tract, and in particular the stomach, submucosal dissection has established itself as a treatment method, then its place in the treatment of colon lesions is not yet clear.

Prevention of bleeding in colon polyps. The risk of bleeding after polypectomy, according to different authors, ranges from 0.3 to 6%. The factors that are associated with high risk, relate:
taking anticoagulants and, to a lesser extent, antiplatelet agents;
large adenomas (more than 2 cm) on a stalk;
proximal localization of the adenoma;
insufficient experience of the doctor.

Large sessile adenomas("sessile") are also associated with an increased risk, as are densely stalked polyps. Blood clotting is an important part of bleeding prevention. Recommendations based on this fact are not as obvious as the conviction with which these recommendations are made.

Most often it is recommended to inject a solution into the tissue adrenaline in a dilution of 1:10,000. For polyps larger than 1 cm in diameter, injection of an adrenaline solution into its base reduces the risk of bleeding. However, studies confirming the effectiveness of this method are based on an insufficient number of clinical observations, and the need to add adrenaline to the injectable solution has not been proven at all (S.-H.Lee, World J. Gastroenterology 2007). It also remains unclear why the injection of saline sodium chloride alone is effective. The explanation, apparently, lies in the fact that it reduces the resistance of the tissue and thereby lengthens the initial phase of cutting when high-frequency electric current is applied. It has also not been completely clarified how the Endoloop loop has a hemostatic effect when removing large polyps (more than 2 cm in size) on a stalk. The results of a comparative study of the effect of a dilute (1:10,000) and a concentrated solution of adrenaline when injected into the base of the polyp turned out to be contradictory. There are no data on the prevention of late bleeding by applying Hamoclip clips, despite the fact that this method of stopping bleeding seems to be the most commonly used.