This lesion was found in the descending colon. It's lifted with our standard EMR solution (volpex, adrenaline and indigo carmine dye).
HOW WOULD YOU NOW BEST APPROACH THE RESECTION?
a) the lift is poor, the lesion appears tethered and I would refer for surgery
b) this is a benign polyp and a piecemeal resection using a 15mm snare would be best
c) the polyp may be malignant and a large, floppy snare would be best to remove the lesion in as few pieces as possible
d) preferable for 'single fragment resection' but a stiff, large snare would be preferable
The lifting is a little 'lob sided' but that is common and not necessarily a 'showstopper'. A polyp of around 3-4cm would have a 1:7 risk or so of harbouring cancer. For this reason, removing the lesion either single fragment or in as few pieces as possible, would be preferable.
It's worth highlighting that when you have a sessile polyp like this, the surface crypt pattern may not accurately reflect what is happening deeper inside the polyp.
So how could this polyp be removed in as few pieces as possible? Of course and ESD is the obvious answer. But it's not possible or appropriate to offer this to every patient. Another possibility would be to do a 'pre-cut' EMR, when you cut a grove around the polyp before resecting it. An 'underwater resection' would be a third possibility
However, the simplest way to remove this as a central main fragment and then some small side-fragments would be with a stiff snare. A stiff snare allows you to push down hard on the polyp and get it off in as few pieces as possible.
Of course there is a far higher than average risk of perforating with a stiff, large snare. Use it with caution and be prepared for trouble. A pre-cut around the polyp could also help in achieving a single fragment resection.
Ultimately, this lesion was resected as a main central fragment and several small side-fragments (image below). The ultimate histology was of a tubulovillous adenoma (TVA) harbouring low grade dysplasia (LGD).