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Tips on handling big polyps that you are not going to remove

Knowing your limits is a very important part of doctoring. As Mark Twain said, “Good decisions come from experience. Experience comes from making bad decisions.” Tackling big polyps with the scope is no exception to this rule. Although techniques for removing large polyps have evolved over the years, and maneuvers that were once deemed “high-risk” are now being taught fairly routinely to junior GI fellows, there is still an individual comfort level that practitioners should identify in themselves and respect.

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Flat “polyp” resection (part two)

I was surprised when the pathologist called me a few days later about the patient, since pathologists usually only call when a result is malignant or unusual. This “polyp” which I estimated to be about 15-mm in greatest diameter was a serrated adenoma (not a surprise) but also contained an 8-mm focus of adenocarcinoma. Luckily, the carcinoma portion of the polyp was completely resected with clear margins on all sides, however this polyp was truly an early-stage colon cancer!

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Flat “polyp” resection (part one)

This lesion exhibits the “mucus cap” sign. There is a thick layer of mucus adherent to the polyp that remains attached even after washing with the water jet on the scope. The mucus cap sign is often seen with a particular type of polyp called a serrated polyp. These are often located in the right side of the colon, and are thought to be easier to miss on colonoscopy due to the flat nature of their growth. Unfortunately, they can still transform into colon cancer.

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