Snare Polypectomy We have discussed the use of the biopsy forceps to remove polyps. That technique is generally limited to the removal of smaller polyps-usually less than 5 millimeters. Larger polyps are generally removed using the snare technique. Just like the use of biopsy forceps, snares can be "hot" or "cold"-meaning that electrocautery is used or not used. A snare is basically a wire lasso that is placed around a polyp, then tightened around the polyp tissue to cut off the polyp.
Polyp Removal Techniques The last post on this blog discussed some of the commonly encountered types of polyps. One of the goals of colonoscopy is to detect potentially pre-cancerous polyp-the distinct advantage of colonoscopy(versus imaging studies such as lower gi x-rays, or so called "virtual" colonoscopy is the ability to not only detect polyps, but to remove them at the same time. There are several techniques that are used by gastroenterologists. The choice of technique may depend on the size and shape of the polyp, as well as the experience, training, and comfort-level of the physician performing the procedure with the various techniques. I will try not to bore you technical details of each approach, but rather, I hope to give you a general idea of each so that if you or a loved one has a polyp removed you can have an idea of what exactly that meant. FORCEPS POLYPECTOMY Forceps are basically like a tiny set of tweezers. They are on the tip of a long wire-type device that we slide down the biopsy channel of the scope, and they emerge from an opening in the tip of the scope while it is in the colon. The assistant can open the forceps, then the physician positions the forceps over the polyp, then the assistanrt closes the forceps, thus grasping the polyp. The physician then basically just pluckes the polyp off the wall of the colon. Forceps can be "cold" or "hot". In the case of a cold forceps, there is no electric cautery involved, whereas in a hot forceps polypectomy, monopolar cautery is used. The advantage of cautery is that it can prevent bleeding, and can help destroy any redsidual polyp tissue on the colon wall that was not grasped with the forceps. The disadvantage is that sometimes the polyp tissue is destroyed by the cautery and difficult for the pathologist
How Are Polyps Removed?
We talked a little bit about colon polyps in our last post. Many patients are curious as to exactly how polyps are removed during colonoscopy. Today we will discuss that very topic. To be honest with you, the techniques we have for removing polyps during a colonoscopy are pretty amazing!
The vast majority of polyps are removed using:
1) Biopsy forceps- “cold” versus “hot”
2) Snare-“cold” versus “hot”
Biopsy forceps can be “cold” meaning that there is no electric current passing through the forceps, or they may be “hot” in which case monopolar electric current is transmitted to the tissue through the forceps. Polyps appropriate for removal with a biopsy forceps are usually quite small-up to 3 millimeters for a cold forceps and up to 4 mm for a hot forceps.
The forceps is really a tiny set of “tweezers” on a long wire that can be passed down a long hollow channel in the colonoscopy. The tweezers can be opened and closed by the technician assisting the colonoscopist. When a tiny polyp is identified, the forceps is slid down the scope, and the polyp is grasped with the open jaws of the tweezers which are then closed. If “hot” forceps are used, an electric current is passed through the forceps to obliterate the tissue, then the polyp is “plucked” off the wall of the colon with the forceps. The polyp tissue is then retrieved and sent to the pathology laboratory. If “cold” forceps are used, the polyp is grasped and plucked off the wall of the colon without any electric current.
Here is what a biopsy forceps looks like:
It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.
Colon Polyps Part I
As a practicing Gastroenterologist, one of the most common situations that arises relates to the question of colon polyps. Polyps of the colon are extremely important! Therefore my mission today is to try to debunk some of the misconceptions regarding colon polyps, and give a clear understanding of this common condition.
First off, what exactly is a polyp? A colorectal polyp is a fleshy growth lining the wall of the colon or rectum. There are a variety of types of polyps, but I will confine my discussion to the two major types. Adenomatous polyps are the most important type, because they are the principal precursor of colorectal cancer. The other type of polyps are hyperplastic polyps. The vast majority of those are small and insignificant, although as I will discuss later there is a small subset of hyperplastic polyps that do have the potential to become cancerous.
Since adenomatous polyps are the main precursor of colorectal cancer, I will focus most of our attention on them. Just to give you an idea about the magnitude of this problem, consider the fact that in the United States alone in 2010, there were 142,570 cases of colorectal cancer diagnosed(4th leading cause of cancer in the US) and 51,370 deaths from colorectal cancer(2nd leading cause of cancer death). There is a 6% lifetime chance of the average American developing colorectal cancer.The appalling part of these statistics in my opinion is that I believe those numbers are far higher than they need to be. Why? Because if precancerous polyps can be identified and removed, we can effectively reduce the risk of colorectal cancer, and in turn the risk of dying of the disease. We, as a society, are doing a much better job of getting this message out. Since colonoscopy was recognized as an effective screening method, and routine screening colonoscopy began to be covered by Medicare, the death rate from colon colorectal cancer has gradually edged down. However, sadly, only about 50% of Americans of the proper age(50 years and up) is getting routine colorectal cancer screening.
So why aren’t we shouting this from a mountaintop and having everyone checked for polyps? Good question. It is a huge public health problem, and like many things, there are a variety of opinions on how to best screen people for colorectal cancer and colorectal polyps. I could spend hours reviewing the different strategies that have been proposed. Let me just summarize by saying that in my opinion, there is no doubt that colonoscopy is the best screening test to look for colon polyps and cancer. But if you have the time and interest, feel free to look at the conclusions of the U.S. Preventative Services Task Force-which goes into great detail about the various options. http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm
So what are the odds that your routine screening colonoscopy will show adenomatous polyps? It is estimated that approximately 25% of Americans at the age of 50 will have polyps on a routine screening exam. The chances of having polyps increases with age. These polyps come in a variety of shapes and sizes. When it comes to polyps, size does matter. In generally, larger polyps are more likely to harbor cancer cells than smaller polyps. As far as shape goes, they may grow on a stem, almost like a cherry(pedunculated polyps) or they may grow fairly flat, more like moss on a tree(sessile polyps). These differences in polyp shape can have important implications as far as the techniques used to remove them.
Pedunculated Polyp
It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.
As a practicing Gastroenterologist, one of the most common situations that arises relates to the question of colon polyps. Polyps of the colon are extremely important! Therefore my mission today is to try to debunk some of the misconceptions regarding colon polyps, and give a clear understanding of this common condition.
First off, what exactly is a polyp? A colorectal polyp is a fleshy growth lining the wall of the colon or rectum. There are a variety of types of polyps, but I will confine my discussion to the two major types. Adenomatous polyps are the most important type, because they are the principal precursor of colorectal cancer. The other type of polyps are hyperplastic polyps. The vast majority of those are small and insignificant, although as I will discuss later there is a small subset of hyperplastic polyps that do have the potential to become cancerous.
It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.
Many of our patients are concerned about the current H1N1 influenza epidemic. As you probably know, both typical influenza and the H1N1 type influenza represent significant health risks. In fact, the Centers for Disease Control has reported their most recent statistics, and as of November 17,2009 there have been 26,315 hospitalizations for influenza and 1,049 deaths from the disease. These statistics include only confirmed cases, proven by laboratory tests. The true statistics are likely quite a bit higher. Naturally, patients want to know what they can do to prevent this illness and whether they should receive the conventional influenza vaccine, the H1N1 vaccine, or both. There is a tremendous amount of information available regarding the current influenza situation on the website of the Centers for Disease control(www.cdc.gov/flu), a government run health agency that has some of the most up to date information and statistics about the disease.
Since the availability of the H1N1 vaccine has been somewhat limited, the CDC has detailed certain groups of people who they feel are a higher priority for the vaccine. Some of these recommendations include :
• Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated;
• Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants younger than 6 months old might help protect infants by "cocooning" them from the virus;
• Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity;
• All people from 6 months through 24 years of age
• Children from 6 months through 18 years of age because cases of 2009 H1N1 influenza have been seen in children who are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and
• Young adults 19 through 24 years of age because many cases of 2009 H1N1 influenza have been seen in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and,
• Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.
The CDC has stated that when there is an adequate supply of the vaccine, that all people age 25-64 should receive the vaccine.
As far as the "regular" seasonal influenza vaccine, the CDC's recommendations are as follows:
• Children aged 6 months up to their 19th birthday
• Pregnant women
• People 50 years of age and older
• People of any age with certain chronic medical conditions
• People who live in nursing homes and other long-term care facilities
• People who live with or care for those at high risk for complications from flu, including:
• Health care workers
• Household contacts of persons at high risk for complications from the flu
• Household contacts and caregivers of children <5 years of age with particular emphasis on vaccinating contacts of children <6 months of age (these children are at higher risk of flu-related complications
There are some people who should not get a flu vaccine without first consulting a physician. These include:
• People who have a severe allergy to chicken eggs.
• People who have had a severe reaction to an influenza vaccination.
• People who developed Guillain-Barré syndrome (GBS) within 6 weeks of getting an influenza vaccine.
• Children less than 6 months of age (influenza vaccine is not approved for this age group), and
• People who have a moderate-to-severe illness with a fever (they should wait until they recover to get vaccinated.)
Gastroenterologists recognize that some of our patients may have medical problems that put them at increased risk for influenza-related complications. The best source of advice for whether you should get a seasonal influenza vaccine or an H1N1 vaccine is your primary care physician. However If you have any questions about whether your gastrointestinal or liver related condition puts you at increased risk for flu related complications, please speak to your Gastroenterologist.
One of the critical questions that remains to be answered in the current healthcare debate is that of preventive services. Preventive services are those that are designed to maintain wellness, and to screen people for conditions that-if caught early-are more likely to be cured than if caught when they are more advanced. It is a commonly held belief that preventive health services can lead to better health outcomes, and can save money along the way. While this statement would seem self-evident, it is not quite as simplistic as it may seem. For example, an editorial in the New England Journal of Medicine from February 14,2008 calls into question whether preventive medicine truly results in economic savings, and the conclusion of the authors is that it does not necessarily. The authors included the director of the Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts–New England Medical Center, as well as a professor of health policy and management at the Harvard School of Public Health, -not exactly academic lightweights.
While one measure of success for preventive health programs is cost savings, surely another is a better health outcome. Even if there is a net increase in overall cost for implementing preventive health programs, such as cancer screening, there may be enough of a societal justification to implement them.
Not all preventive services were created equal.It turns out that some preventive services give a “better bang for the buck” than others. Some of these “high value” services include smoking cessation, counseling for use of aspirin, colorectal cancer screening, and appropriate vaccination for influenza. These services are currently underutilized. It is estimated that 90% utilization of such measures would result in 100,000 lives saved each year.
Where does President Obama stand on the matter? Is the current climate in Congress one which will expand preventive services regardless of the cost and the cost effectiveness involved? Or will Congress give only lip service to preventive services (as seems to be the case with malpractice reform)? While we may never know the inner thinking of some of the key politicians involved, including President Obama(a sad commentary on transparency in government!), at least we can try to read the tea leaves based on some of their public comments.
President Obama, in his speech to the joint session of Congress in September of this year certainly talked a good game regarding prevention. The President argued that "there's no reason we shouldn't be catching diseases like breast cancer and colon cancer before they get worse. That makes sense." This endorsement of colorectal cancer screening was welcomed by the American College of Gastroenterology. "We know screening for colorectal cancer is good health policy, and makes good economic sense," commented ACG President Dr. Eamonn Quigley. Studies have shown that for every dollar spent by Medicare for this life-saving test cuts about $3 in long-term medical costs. The New England Journal of Medicine says that a colonoscopy colorectal cancer screening is one of the few preventive services shown to reduce future health care costs. "That's a good return on investment in any business - especially when you're saving lives. When screening procedures detect colon cancer early, nine of ten patients beat the disease. In the absence of screening, colon cancer is usually found too late and many patients die. Those are starkly different outcomes that we have the power to change," added Dr. Quigley. Will Congress exercise good judgment regarding preventive health services? Let us hope that they expand those preventive services that have proven benefit, and shun those that do not. This is a tall order-when even the medical community is divided about which services are worthwhile. However, there is little question that colonoscopy for colorectal cancer screening is effective in saving both lives and money. Let us hope that our political leaders put the appropriate resources into this type of preventive services. Now would be a great time to contact your Senator and Congressman to urge them to include colon and rectal cancer screening as a priority in any health care bill that emerges.
Fielding J. Does Preventive Care Save Money. N Engl J Med 2008;358: 2847-2848
Cohen J, Neumann P, Weinstein M. Does Preventive Care Save Money? Health Economics and the Presidential Candidates. N Engl J Med 2008; 358:661-663
Preventive care: a national profile on use, disparities, and health benefits. Washington, DC: Partnership for Prevention, 2007.
