Why have I been provided with this leaflet?
A polyp has been found in your bowel and we would recommend removal for precautionary measures. This leaflet explains to you more about your condition and what is involved in its treatment.
What is a colonic polyp?
A polyp is a small growth that sometimes forms on the lining of the bowel. Most small polyps are harmless but if they are left to grow into large polyps they can become cancerous.
Larger polyps (more than 2cms) have a small chance (1 in 10 or 10%) of having cancerous cells. We can still remove these polyps as part of your endoscopic procedure and this may be all that is required. Occasionally it is not possible to remove some large polyps this way and therefore an operation may be required. Most polyps do not cause any symptoms but in some cases they can cause bleeding or a change in bowel habit.
Why have I been referred to the complex polyp service?
The removal of larger polyps carries greater risk of unplanned events including bleeding or perforation. The complex polyp service undertakes these procedures on a regular basis and hence has the experience to reduce the chance of such events.
What are the benefits?
There is a small but significant chance that there are cancerous cells in your polyp. Polyps usually grow and may remain benign or they may turn into a cancer in the future. For this reason we recommend removal of the polyp to identify cancer early and to prevent cancer occurring later. Large polyps can cause symptoms and removing them can improve your quality of life.
How do we remove large polyps endoscopically?
As outlined in “having a colonoscopy” leaflet (number 320) you will receive bowel preparation before your procedure and you may receive sedative drugs during the test. Please take time to read and follow the instructions carefully.
Endoscopic removal of larger polyps can take longer than a standard or diagnostic colonoscopy but this can vary depending on the size and position of the polyp. Please be aware in some cases you can be in the Endoscopy department for several hours.
There are two ways that we can remove a polyp endoscopically. Endoscopic mucosal resection (EMR) and Endoscopic Submucosal Dissection (ESD).
Endoscopic mucosal resection (EMR)
The Endoscopist will firstly use the endoscope (camera) to find the polyp. Next a special needle is passed through the camera and inserted into the base of the polyp as shown below. Fluid is injected through the needle to raise the polyp away from the bowel wall. A wire snare is then passed through the camera and positioned around the raised polyp. The snare is pulled tight and an electric current is passed through the snare which burns any blood vessels as the polyp is cut off. If the polyp is very large, it may be removed in a number of pieces in the same way. Once the polyp has been removed, it is retrieved so that it can be sent to the pathology lab for further analysis.
Endoscopic Submucosal Dissection (ESD)
The Endoscopist finds the polyp as before (it is usually in the rectum). Then a special tool is used to carefully cut around and underneath the base of the polyp This takes time and slowly the polyp is peeled off from the bowel wall and finally it can be removed in one piece. Rectal polyps are most suitable for ESD as the risk of perforation is much lower compared to the rest of the colon.
Risk of Endoscopic Mucosal Resection – EMR
The main risks are:
Perforation – this means a tear in the bowel wall. For EMR, this occurs about once in every 100 patients (1%). Perforation can occur up to 14 days after the test. Perforations can heal with readmission and strong antibiotics and sometimes they can be treated with the endoscope. However sometimes an emergency operation is required.
Cancer in the Polyp and risk of spread of cancer. If cancer is found in the polyp you may need an operation to remove part of the bowel at the site of the polyp. EMR removes polyps in pieces and the depth of invasion of the cancer can be unclear. This means that we are usually not able to tell if the cancer is superficial (no need for an operation) or deep (you should have an operation as the cancer has a higher chance of spreading to the liver).
Recurrence– even when all the parts of the polyp visualized on the camera are completely removed the polyp can come back in the same location. This is called recurrence. Studies show this can happen in up to 10% of patients. With EMR technique you always need a site check in three to six months and 18 months. Usually this can be dealt with by a repeat camera test undertaken in three to six months. Sometimes the recurrence may be persistent needing more than one attempt at treatment three months apart
Risks of Endoscopic Submucosal Dissection (ESD)
The main risks are:
Perforation – this means a tear in the bowel wall. For ESD, this occurs about once in every 20 patients (5%) but if in the rectum this is often less serious. These tears are usually small and are dealt with during the procedure. Perforation can occur up to 14 days after the test. Perforations can heal with readmission and strong antibiotics and sometimes they can be treated with the endoscope. However sometimes an emergency operation is required.
Cancer in the Polyp and risk of spread of cancer. If cancer is found in the polyp you may need an operation to remove part of the bowel at the site of the polyp depending on the depth of invasion as well as other factors. ESD removes polyps in one piece so we can usually tell the depth of invasion of the cancer. This means that we can tell if the cancer is superficial (no need for an operation) or deep (you should have an operation as the cancer has a higher chance of spreading to the liver).
Recurrence and routine site checks– ESD can usually remove the whole of the polyp in one piece. This occurs in 65% (or two in three cases). If this occurs, you do not need to have the two repeat site checks. If we have removed the polyp in one piece but with incomplete margins, then we routinely arrange a site check at 6 and 18 months. Studies show that recurrence with ESD is approximately 1%.
General risks for all endoscopic procedures
Bleeding – bleeding may occur once in 2 – 5 out of 100 patients (2-5%), with the highest risk when removing large polyps from the right side of your colon. Bleeding can occur up to 14 days after the procedure. Blood transfusion or further endoscopies may be required. Very rarely emergency surgery may be needed to stop it. If you have a condition which may increase your risk of bleeding such as Haemophilia, von Willebrands disease or low platelets please inform the Endoscopy department.
Incomplete removal – sometimes the Endoscopist cannot remove the entire polyp. If this happens, you may need a further attempt using the endoscope or an operation might be planned later.
Complication of sedation– there is a small risk that the sedative may affect your breathing. We aim to reduce this risk by assessing your general health prior to the endoscopy and you will be closely monitored by qualified staff during and after the examination.
What happens if the endoscopist does not think that EMR or ESD is possible?
In this case, you will usually be seen in clinic and the doctor will discuss whether you need to have an operation to remove the polyp.
Are there any other ways of dealing with my polyp?
There are two main alternatives to having an EMR or ESD
- We could decide to leave the polyp as it is and do nothing. This option may be preferable in patients who have significant health problems. The rationale being that the polyp is unlikely to cause problems in the patient’s lifetime.
- The polyp could be removed by having an operation on the bowel. This is usually a straight forward procedure which may be an open or key-hole procedure but carries the risks of general anaesthetic and surgical complications such as infection and delayed healing. There is a risk that the join in your bowel may leak, requiring further surgery. It will also leave you with a scar on your abdomen. Sometimes, surgery can require the formation of a stoma (bag on your abdomen), although this may only be temporary. The risks of surgery may be considerably higher if you have other medical conditions and does include a risk to your life.
These options will be discussed with you in detail at your pre assessment appointment and by the Endoscopist undertaking the procedure.
After the examination
We may decide to admit you after the procedure for monitoring purposes. If we feel that you can go home that day you will be allowed to rest quietly on a trolley. You will be cared for by qualified nursing staff in the recovery area of the department. You will usually be ready to go home approximately 30 to 40 minutes after the procedure has ended. Please ensure that a responsible adult is able to collect you from the department, take you home and stay with you for 24 hours if you have requested sedation. Most Endoscopic submucosal dissection (ESD) procedures and many larger EMR procedures are routinely admitted after the procedure. This is usually for your own safety and you should be allowed home the next morning.
How will I know the results of my test?
The Endoscopist performing the procedure will often be able to give you some results straight after the procedure. Before you are discharged you will be given clear details concerning follow up arrangements and aftercare information. A full report will be sent to your GP and/or hospital consultant. You will be given contact details in the event of any complications that may occur. After two weeks there is little or no chance of any complications post polypectomy.
The polyp is usually retrieved during the Endoscopic procedure and sent to the pathology laboratory for further analysis. It can take up to two weeks before a result is available. Your consultant will then be in touch with you regarding these results. Sometimes decisions about further treatment can only be made once these results are available.
Contact numbers
If you have any further questions, you should contact the following:
Main Switchboard
Endoscopy
Endoscopy Department
Queen Elizabeth Hospital
Sherriff Hill
Gateshead
Tyne and Wear
NE9 6SX
Monday – Friday
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