Intestinal polyps: signs, symptoms, treatment in adults. Principles of Polyp Removal by Endoscopy Additional Testing Methods

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Previously, it was believed that the removal of polyps in the intestine is advisable only for large or multiple neoplasms. However, the statistics of the transformation of these benign tumors into malignant ones (10-30% of cases) showed specialists that it is important to get rid of even small polyps for the prevention of cancer.

Today, endoscopic treatment is used to remove polyps in the colon and small intestine, except in cases where the neoplasm is located in the parts of the intestine that are inaccessible to the endoscope. Large and multiple polyps, a high risk of degeneration into cancer - an indication for a segmental resection operation.

Treatment tactics

If a small polyp is found, expectant tactics may be prescribed.- the doctor monitors the dynamics of tumor growth throughout the year, and if no significant changes are found, the operation to remove the polyps is not performed. However, in this case, it is imperative to continue to be regularly examined in order to eliminate the risk of rebirth in time.

Due to the psychology of Russian patients, in most cases, instead of expectant tactics, endoscopic removal is immediately prescribed. People believe that there is no need to worry about small polyps, and they ignore doctors' appointments for repeated examinations, so specialists immediately approach the problem radically - this is the safest option. Even a small neoplasm can quickly become malignant.

There is no conservative treatment for intestinal polyps - it is simply ineffective.

In the presence of other possible complications of polyps - bleeding, persistent diarrhea, profuse mucus secretion or severe inflammatory processes - expectant tactics are not used, the operation is prescribed immediately.

Removal of polyps in the colon

In most cases, removal of polyps in the rectum with an uncomplicated course is carried out endoscopically during colonoscopy. The same treatment applies to sigmoid polyps. The operation is called polypectomy.

Preparing for surgery

In preparation for the operation, it is necessary to cleanse the intestines. To do this, a day before the patient is shown to drink at least 3.5 liters of clean water, food includes only liquid, light food. Do not eat or drink the evening before the procedure. A cleansing enema may be prescribed.

Sometimes the use of a special solution with water and a laxative is prescribed. Most often it is a solution of polyethylene glycol (4 liters), which is drunk for 180 minutes on the evening before the operation, or lactulose preparations (solutions of Duphalac or other drugs containing this component). In the second case, 3 liters of liquid are divided into two doses - before lunch on the day before the operation and in the evening. After taking these solutions, diarrhea should open, possibly bloating and pain in the abdomen.

If the patient is taking blood-thinning medications (Aspirin, Warfarin, Ibuprofen, etc.), it is important to inform the attending physician about this. Most likely, they will have to be abandoned 1-2 days before the colonoscopy.

Polypectomy

colonoscopy

Colonoscopy is performed only in specially equipped rooms. The patient lies down on the couch with his left side, drugs for anesthesia are administered. Access to polyps is carried out through the anus, a flexible and thin endoscope (colonoscope) with a small flashlight and a video camera is inserted into it, which allows you to visually monitor the progress of the operation.

If the polyp is flat, a special drug (often adrenaline) is injected into it, which raises it above the mucosal surface. The neoplasm is removed using an instrument with a diathermic loop at the end. She is hooked at the base of the polyp and undercutting it, while simultaneously applying an electric current to cauterize the damaged area and prevent bleeding.

Important! Cut polyps are sent for histological analysis without fail, only after that a final diagnosis is made. If atypical cells are found that indicate tumor malignancy, the patient is assigned a partial bowel resection.

In rare cases, laser surgery is used to remove polyps. It is not as effective as colonoscopy, since it is not possible to obtain tissue material for histology (the polyp is simply burned out to the root) and there are difficulties with visual control (due to smoke).

Transanal excision of polyps

If it is not possible to carry out a colonoscopic operation, direct surgery through the anus may be prescribed. Such treatment is not possible if the polyps are located more than 10 cm from the anus.

Before the operation, local anesthesia according to Vishnevsky is performed, sometimes general anesthesia is prescribed. A rectal speculum is inserted into the anus. The base / leg of the polyp is excised with special instruments (Billroth's forceps), the wound is sutured with 2-3 catgut nodes.

If the polyp is located at an interval of 6-10 cm from the opening, then during the operation, after the introduction of the rectal speculum, the sphincter is relaxed with the fingers, after which a large gynecological speculum is inserted, with which the intestinal wall not affected by polyps is pulled aside. Then a short mirror is inserted and the neoplasm is removed in the same way. Polyps are sent for histology.

Segmental colon resection

Such an operation is prescribed only if there is a high risk of malignancy of a colon tumor or the presence of multiple closely spaced polyps. It is performed under general anesthesia. Depending on the location of the neoplasms, the type of operation is chosen:

• Anterior rectal resection... It is prescribed for a tumor above 12 cm from the anus. The doctor removes the affected portions of the sigmoid colon and rectum, and then sutures the remaining portions of the intestines together. Nerve endings, healthy urination and sexual function are preserved, feces are kept in the intestines normally.
• Low front... It is used when the tumor is located 6-12 cm from the anus. Part of the sigmoid and the entire rectum is removed, the anus is preserved. A temporary "reservoir" is formed to retain feces and stoma (part of the intestine is excreted through the peritoneum), which prevents excrement from entering the healing stitched area of ​​the intestine. After 2-3 months, a reconstructive operation is performed to close the stoma and return the normal function of defecation.
• Abdominal anal... It is carried out when the neoplasms are located at a distance of 4-6 cm from the anus. Part of the sigmoid colon, the entire rectum, and possibly part of the anus are removed. A stoma is formed, which is closed after 2-3 months.
• Abdominal perineal. It is indicated when the tumor is located close to the anus. A part of the sigmoid colon, the entire rectum, anus and part of the pelvic floor muscles are removed. A permanent stoma is formed, since it is impossible to maintain the function of normal bowel movement (the sphincter is cut out).

Important! When a permanent stoma is opened, the patient is given recommendations for caring for it and organizing life activities. In most cases, a high quality of life can be achieved despite the inconvenience and aesthetic defect.

Treatment of polyps in the small intestine

Single small polyps of the small intestine on the pedicle are removed using enterotomy; in the presence of other neoplasms, resection of the small intestine is indicated.

Enterotomy

This surgery is dangerous, it much more serious than endoscopic methods and requires high qualifications of a surgeon. Stages of carrying out:

1. The patient is put into a state of general anesthesia.
2. A transverse incision is made over the required area of ​​the small intestine with a scalpel or electric knife.
3. Polyps are excised through the cut area and sent for histology.
4. All incisions are sutured.

After the operation, the patient should be in the hospital under the supervision of a surgeon and a gastroenterologist. She needs bed rest, pain relievers are prescribed to relieve pain, a strict diet is followed. With insufficient professionalism of the doctor, narrowing of the small intestine, bleeding is possible.

Segmental small intestine resection

The operation is carried out by an open or laparoscopic method, the second is preferable, since it has fewer negative consequences - the scars are smaller, the probability of infection is lower, and the patient is quickly rehabilitated. Preparation for the intervention is carried out according to the standard scheme described above. The execution proceeds as follows:

The operation lasts up to 3 hours, after which the patient is gradually removed from anesthesia (up to 2 hours). Recovery takes 3-7 days in a hospital. When performing an open resection, one large incision of the peritoneum is performed, rehabilitation takes up to 10 days in a hospital, otherwise there are no differences.

Rehabilitation period

Within 2 years after removal of polyps, there is a high risk of recurrence and bowel cancer. Patients are shown to undergo regular examinations - every 3-6 months. The first examination is scheduled 1-2 months after the operation. Subsequently (from the third year after treatment), an examination is required every 12 months.

• Do not ignore preventive examinations, come to the doctor at the appointed time, follow his recommendations.
• Give up bad habits, smoking and drinking alcohol is highly undesirable.
• You can not engage in heavy physical labor, lift weights - this will increase the risk of bleeding.
• Avoid hypothermia and overheating, do not stay in the sun for a long time, give up the tanning bed and follow the prescribed hygiene measures.
• Try to limit stress, prevent overwork. Healthy rest plays a significant role in recovery.

During the rehabilitation period, you must follow a diet. During the first week after endoscopic surgery, you should eat chopped food, mashed potatoes, soft liquid cereals. Hard and indigestible foods rich in coarse fiber are excluded. Meals should be fractional - eat up to 6 times a day.

Important! After open operations, a doctor prescribes a diet, it is very tough and excludes almost all food.

You will have to urgently consult a doctor if you have the following complications:

• Fever, chills;
• Heaviness in the abdomen, pulling pains;
• Redness, swelling in the anus;
• Stool blackening, blood impurities during bowel movements, constipation;
• Nausea, vomiting and other signs of intoxication.

This may indicate the dangerous consequences of the operation, including bleeding, perforation of the intestinal wall, intestinal obstruction, enterocolitis, the formation of fecal stones or malignancy.

Average prices

The cost of surgery to remove intestinal polyps varies greatly depending on the clinic, the qualifications of the doctor and the amount of work. The approximate range of prices is shown in the table.

Free treatment is possible in state clinics under the compulsory medical insurance policy. It is also possible to help with the VMP program, if the malignancy of the polyp is confirmed.

Patient reviews often mention doubts about the need for an operation to remove polyps in the intestine. However, doctors unanimously argue that its implementation is justified, since it significantly reduces the risk of cancer. People who have undergone minimally invasive surgery are satisfied with the results and speed of rehabilitation. The main thing in treatment is to find an experienced and reliable doctor, whose help you can rely on.

Video: endoscopic removal of intestinal polyps

Video: polyps of the large intestine in the program "On the most important thing"

Removal of polyps in the intestine is a surgical operation consisting in the removal of these benign neoplasms that attach to the intestinal walls and grow deeper into the intestinal lumen.

Having a habit of growing in any part of the large or small intestine, polyps, differing in their size and structure, can be discrete and multiple in nature.

Discrete polyps are distinguished by a single location of several benign neoplasms located far from each other.

In the presence of hundreds of such neoplasms, they speak of the multiple nature of polyps. If their number significantly exceeds this indicator, the patient is diagnosed with diffuse polyposis. It is in this case that the risk of their malignancy is greatest.

Indications and contraindications for the operation

The indication for removal is:

• the presence of bleeding and profuse mucus from the anal canal;
• feeling of severe discomfort;
• constant pain in the lower abdomen;
• violation of active intestinal motility;
• development ;
• ulceration of the intestinal mucosa.

Surgical removal of polyps in the intestine is categorically contraindicated if the patient has:

• diabetes mellitus;
• infectious diseases;
• pacemaker;
• an acute inflammatory process in the intestinal area subject to surgery, since this increases the likelihood of perforation of the intestinal wall affected by polyps.

Training

Since most of the intestinal polyps can be removed during the procedure of colonoscopy and sigmoidoscopy, the algorithm for preparing for the operation is reduced to an identical set of measures to cleanse the intestines, performed before these diagnostic studies.

In clinical practice, the following options for preparing for the colonoscopy procedure are most often used:

• The patient is ordered to follow a strict non-slag diet 48 hours before the procedure. In the second half of the day preceding the operation, the patient must take castor oil. One home cleansing enema is performed in the evening and three (at half-hour intervals) in the morning before the colonoscopy. Since the procedure is usually scheduled for the first half of the day, eating is contraindicated. A few hours before the operation, the patient can drink a cup of weak tea or a glass of juice.
• The second preparation option, which is extremely in demand today in clinics around the world, is based on the method of cleansing the intestines with the help of the drug Fortrans. To prepare the medicine, one sachet of powder is dissolved in 1000 ml of water. The prepared solution is taken in a glass every twenty minutes in the evening hours on the eve of the scheduled operation. For patients freed from the need to follow a slag-free diet and perform cleansing enemas, this preparation method is more attractive. The big disadvantage of this option for cleansing the intestines is that not every patient is able to drink such an amount of the drug in such a short time. In some patients, taking Fortrans can provoke bouts of nausea and vomiting, a feeling of discomfort and heaviness in the abdominal cavity. Usually, this symptomatology is typical for patients suffering from concomitant diseases.

A large number of complaints forces physicians to search for new dosage regimens for Fortrans. The most common are the following options:

• It is proposed, by dividing the entire prepared solution into two equal parts, to take one half of it in the morning, and the other half in the afternoon hours of the day preceding the operation. On the day of surgery, the patient should drink another liter of the medicinal solution.
• According to the second option, the patient takes two liters of the diluted drug in the afternoon, preceding the procedure for removing the polyps. Another liter of medicine is taken by him in the morning of the operating day. According to reviews, it is this option of bowel cleansing that is most tolerated by patients; in addition, with it, there are significantly fewer side effects than with all the methods described above.

The use of Fortrans cannot help patients suffering from severe forms of heart failure and erosive and ulcerative intestinal lesions, in which the intake of such an amount of liquid is simply contraindicated.

In these cases, forlax osmotic laxative is used to cleanse the intestines, which is used to relieve constipation in adult patients. The big advantage of this drug is that one serving dissolves in just a glass of water.

Since the action of Forlax gives a result 24 or 48 hours after administration, patients are prescribed two sachets of this drug for one day. They are taken during breakfast in the morning for 72 hours before the scheduled operation.

In some cases, a scheme is used when the patient is prescribed to take two sachets of forlax in the morning and the same amount in the evening. Thanks to these actions, it is possible to unload the proximal intestine. To cleanse its other departments, a light enema is performed.

Sometimes, instead of an enema, they practice taking a half dose of the drug on the eve of the operation. No complications after bowel cleansing with forlax have been reported in medical practice.

Another advantage of using forlax is the absence of sugar in its composition, which makes it possible to take it to diabetics and patients who have contraindications to taking galactose.

Methods for removing polyps in the intestine

Due to its low effectiveness, conservative treatment of polyps is used only if there are serious contraindications for performing surgery or for temporary relief of symptoms.

During surgery, each detected polyp is removed, followed by histological examination in order to identify cancer cells.

According to experts, a timely performed surgery to remove polyps is the leading preventive measure to prevent colorectal cancer.

In modern medical practice, operations are most in demand:

• endoscopic polypectomy with electrocoagulation of the removed neoplasm;
• transanal excision of the polyp;
• removal of benign neoplasms by colotomy.

Quite often, polyps in the intestines are removed during a diagnostic colonoscopy procedure. In this case, the diagnostic procedure is easily transformed into a therapeutic one.

Sometimes in this way even malignant polyps are removed, which have a leg and are devoid of a network of venous and lymphatic vessels, but only if the degeneration has affected only the head of the neoplasm.

Endoscopic polypectomy

This type of operation is used in relation to benign neoplasms localized in the middle of the intestine. One of the minimally invasive intraluminal surgical procedures, endoscopic removal of intestinal polyps is most often performed using local anesthesia.

Video about endoscopic removal of intestinal polyps:

In the course of the operation, several stages are clearly traced:

• first, an endoscope is brought into the patient's intestines to the site of localization of the polyp;
• a lead plate (passive electrode) is bandaged to the patient's lower back;
• fixing the endoscope at the level of the polyp to be removed, a special end loop is introduced into its biopsy canal, which acts as a second electrode and thrown onto the base of the benign neoplasm;
• the loop is gradually tightened and a high frequency current is applied to it;
• as a result of a two-second exposure to the current, the place surrounded by a hot loop is charred, leading to reliable sealing of the ends of the cut vessels;
• after that, the specialist controls the hemostasis process;
• if necessary, carry out measures for additional electrocoagulation of the base of the removed polyp;
• the cut polyp is removed from the patient's body.

Large neoplasms are removed by lumping, since a too deep burn of the intestinal wall is fraught with its perforation and an explosion of intestinal gases. To remove large polyps, biopsy forceps are used instead of the endopsy.

Pinching off parts from the head of the neoplasm is carried out in several stages. The tactic of phased removal is also used with the multiple nature of polyps with a heap of neoplasms.

Endoscopic polypectomy can be performed either by a qualified endoscopist or by a proctologist skilled in both diagnostic and surgical curative colonoscopy.

With endoscopic removal of large (over two centimeters) neoplasms, villous or multiple polyps, a control endoscopy procedure is performed after a year. If there is no recurrence of polyposis, it is recommended to monitor the state of the intestine with a colonoscopy every three years.

Laparoscopy

Laparoscopic operations are used in relation to large benign neoplasms (over two centimeters) in size.

Unlike classical surgeries that require large incisions, they are performed through small punctures in the abdominal wall using special laparoscopic surgical instruments.

Operations of this type require the use of general anesthesia and a fairly long rehabilitation period.

Laparotomy

If it is impossible to remove polyps by endoscopic polypectomy (usually this applies to polyps with a wide base), a laparotomy (with opening of the abdominal cavity) operation is performed to excise them through an incision in the wall of the affected intestine.

To remove such polyps and hairy neoplasms on thick legs, colotomy is also used - an operation that requires access through the abdominal wall. Through an incision in the lower iliac region or a lower median incision, the sigmoid colon affected by polyposis is removed.

Having groped the location of the polyp, soft pulp is applied to both ends of the extracted intestine and, after making a longitudinal incision of the intestinal wall, the neoplasm is excised along with a part of the adjacent mucous membrane tissues (after excision, sutures are applied to them). For suturing the intestinal wall, a seam is used in two rows, and for the abdominal wall - a deaf layer-by-layer.

Bowel resection

Intestinal resection is an operation to eliminate polyps, involving the need to cut the abdominal wall and remove a part of the intestine affected by multiple neoplasms. This method is used in relation to the accumulation of polyps localized in a specific area of ​​the intestine.

If this congestion is concentrated in the upper segment of the rectum, an anterior resection is performed. In the course of the surgical intervention, it is this part of the rectum, together with the lower segment of the sigmoid colon located above it, which is to be removed. At the final stage of the operation, the ends of both intestines are sutured.

If the accumulation of neoplasms is concentrated in the very center of the rectum, a low anterior resection is performed.

Localization of polyps in the lower segment of the rectum is an indication for transanal excision performed through the anal canal. Full recovery of a patient who has undergone bowel resection requires at least four weeks.

Complications

Polypectomy surgery can lead to a number of complications, the most common of which are:

• Bleeding. The likelihood of occurrence persists for ten days after removal of polyps. Bleeding from the anus, which developed the very next day after polypectomy, indicates insufficient coagulation of the base of the removed polyp. Bleeding that occurs a few days after the operation is most often due to the rejection of a blood clot formed at the ends of the cut blood vessels. The intensity of both early and late bleeding can be either insignificant or significant enough to threaten the patient's life. In this case, an emergency surgery is necessary, carried out with the help of endoscopic instruments and consisting in cauterization (coagulation) of bleeding blood vessels. If it was not possible to stop bleeding with the help of coagulation, specialists resort to laparotomy - an operation that requires opening the abdominal cavity.
• Damage (perforation) of the intestinal walls. This complication can occur both during and after surgery. The formation of a hole in the intestinal wall is a consequence of a deep burn resulting from cauterization of a removed polyp. Through this opening, the contents of the intestine can enter the abdominal cavity, giving impetus to the process of infection. To eliminate this complication, a laparotomy (incision of the abdominal wall) is performed, followed by suturing of the opening that appears and applying it (it is necessary in order to temporarily exclude the injured section of the intestine from the passage of feces). After the final healing of the eliminated defect (usually after 8-16 weeks), the colostomy is removed.
• Recurrence of benign neoplasms. After surgery for excision of polyps, 15% of patients remain at risk of their recurrence within the next two years.

Postoperative recovery

The most important component of the postoperative period for a patient who has undergone surgery to remove polyps in the intestine is careful adherence to a gentle diet that helps to restore the motor-evacuation functions of the intestine.

The therapeutic diet of the operated patient consists of three stages:

• The first stage occurs immediately after the operation and lasts three days after it. During the first 24 hours after surgery, the patient is completely prohibited from eating and drinking. After this period, he is allowed to quench his thirst with a small (no more than 50 ml) amount of water, a little later - to drink a little vegetable broth and compote. Twelve hours later, the patient is offered a little rice broth, meat broth or jelly. All restrictions are aimed at minimizing the motor activity of the intestine and reducing its excretory functions, since the digestive enzymes and bile secreted during the digestion of food can have a negative effect on the condition of the seams and injured tissues.
• After 72 hours after surgery slimy soups, thin cereals (from rice, millet and oatmeal), soufflé from lean meat are introduced into the patient's diet, carefully monitoring his condition. If, after eating a particular dish, the patient experiences the appearance of pain or increased gas formation, it is removed from the diet. The goal of this phase of the therapeutic diet is to normalize the stool and gradually increase the load on the intestines.
• Two weeks after the operation, the third stage of the gentle diet begins.(lasting at least four months). Eating foods rich in coarse plant fibers is detrimental to the operated patient. His diet should consist of broths, vegetable and cereal soups, mashed cereals, diet pates and soufflés.

The following are completely excluded from the patient's diet:

• all kinds of spices, hot seasonings, sauces and salt;
• sour, salty, peppery and spicy foods;
• mushrooms (in any form);
• fatty fish and meat;
• raw fruits and vegetables;
• canned foods;
• too hot or cold food;
• freshly baked bread. Instead of fresh bread, which causes fermentation in the intestines, the patient is advised to use crackers. For the same reason, he should avoid eating legumes, asparagus and nuts.

The preferred methods of cooking food should be boiling, baking, and steaming. Fruit compotes and teas, herbal teas, milk and kefir will be useful as a drink.

A patient who is recovering should take food (at least six times a day) at the same hours, in very small portions: the motor functions of the intestines will improve from this, and the load will not be too significant.

A true (adenomatous) polyp is called the growth of the glandular epithelium, which rises above the level of the mucous membrane.

True rectal polyps are often confused with fibrous polyps and hypertrophied anal papillae, which are located in the lowest part of the intestine - the border of the rectum and the anal canal and are essentially an overgrowth of scar tissue or transitional epithelium. Therefore, if the doctor diagnosed "rectal polyps", it is necessary to clarify which polyps are in question - true, fibrous, or the doctor thus characterized the anal papillae.

Etiology and pathogenesis

It is very difficult to establish the incidence of benign colon polyps, since they are most often asymptomatic. They are found most often by chance in patients who are examined for intestinal discomfort, pathological discharge from the anus, etc. In this regard, a close to the true frequency of polyps can be established only as a result of targeted preventive examinations of the population or autopsies. As a result of the work of Russian and foreign scientists, it was found that the frequency of detection of colon adenomas (when using only sigmoidoscopy) ranges from 2.5 to 7.5% of the total number of patients examined. However, the true frequency of their occurrence is undoubtedly higher, since during the examination the authors did not examine other parts of the colon, in which about 50% of all colon adenomas are located.

According to the literature, the frequency of detection of colon polyps at autopsies for economically developed countries averages about 30%. According to the State Research Center for Surgery (1987), when studying the results of preventive examinations (digital examination and sigmoidoscopy) of two groups of patients (15,000 people) - practically healthy and complaining of discomfort in the anorectal region - it was found that in the structure of diseases of the colon, polyps were only 16 %, while in the group of practically healthy persons this indicator is much higher - 40.6%. This difference is due to the fact that some patients, whose polyps are asymptomatic, do not fall into the field of vision of doctors.

The etiology of polyps of the rectum and colon has not been clarified. The works in which the viral nature of these diseases is studied are of a theoretical nature, as well as the creation of a model of colonic polyposis in animals.

An increase in the incidence of benign colon tumors is associated with the influence of the environment (megacities, the presence of large industries), a decrease in physical activity. An important factor influencing the increase in the incidence of colon disease, many researchers consider the change in the nature of the population's diet in the context of industrialization.

It has been established that the main feature of the diet of residents of economically developed countries is the predominance of high-calorie foods with a high content of animal fats in the diet with a small amount of fiber. All this leads to the fact that the chyme, which contains little fiber, enters the colon, which affects the decrease in the motor activity of the intestine, and a large amount of bile acids, which, as found, in the process of digestion are converted into substances that have a carcinogenic effect on the mucous membrane. A decrease in the rate of passage of chyme through the intestine creates a longer contact between carcinogens and mucous membranes. All this causes a disturbance in the microbial landscape, which in turn changes the composition of enzymes of microbial origin.

Some researchers have established a certain relationship between the frequency of detection of adenomas and the male sex of the deceased, as well as diseases such as atherosclerosis, malignant tumors, diverticulosis and other diseases of the gastrointestinal tract, chronic nonspecific lung diseases.

Pathological anatomy

According to the International Histological Classification of Tumors, benign neoplasms of the colon are presented as follows.

1. Adenoma:

a) tubular (adenomatous polyp),

b) villous,

c) tubular-villous.

2. Adenomatosis (adenomatous intestinal polyposis).

Tumor-like lesions.

a) Peitz-Jeghers polyp and polyposis;

b) juvenile polyp and polyposis.

Heterotopia.

Hyperplastic (metaplastic) polyp.

Benign lymphoid polyp and polyposis.

Inflammatory polyp.

Deep cystic colitis.

Endometriosis

Hyperplastic polyps look like small (up to 0.5 cm in diameter), slightly rising above the level of the mucous membrane of the formation of a soft consistency and normal color. They are characterized by elongation and cystic expansion of the crypts. The epithelium in such polyps is sawtooth convoluted, with a reduced number of goblet cells.

Glandular and glandular-villous (tubular adenomas) are larger formations (up to 2-3 cm in diameter), which, as a rule, have a pronounced pedicle or wide base. In color, they are close to the surrounding mucous membrane, but have a denser consistency, move along with the mucous membrane, rarely bleed and ulcerate. According to the degree of morphological differentiation of the epithelium, three groups of tubular adenomas are distinguished: with weak, moderate and significant dysplasia. With a weak degree, the architectonics of the glands and villi are preserved; the number of goblet cells decreases, their nuclei are extended, slightly increase, but are located in one row; the number of mitoses increased slightly. With severe dysplasia, the structure of the glands and villi is disturbed, the nuclei can be located in all parts of the cell, their increase is noted, many mitoses appear, including pathological ones; the goblet cells disappear. Moderate dysplasia is characterized by intermediate changes.

Villous adenomas have a slightly lobed surface, resembling a raspberry berry. In size, as a rule, there are more tubular adenomas.

Juvenile polyps cannot be classified as adenomas, because they do not have glandular hyperplasia and atypical changes in the glandular epithelium. Such a formation, rather large, often hangs down into the lumen of the intestine on a long leg, smooth, more intensely colored (bright red, cherry-colored). On microscopy, it is a cystic-granulating polyp, the enlarged glands of which are lined with typical intestinal epithelium and contain a mucous secretion.

Classification

According to the clinical picture, all benign colon tumors can be divided into two main groups: epithelial tumors, which occur most often (92%) and pose the greatest risk of growth and malignancy, and rare neoplasms, the frequency of individual forms of which ranges from 0.2 to 3, 5% (8% in total), the likelihood of their malignancy is small, except for melanoma and carcinoid.

The subdivision of epithelial tumors by histological structure, size and multiplicity factor is of great clinical importance.

According to the histological structure, polyps are divided into:

- hyperplastic (2%);

- ferruginous (51.6%);

- glandular villous (21.5%);

- villous (14.7%).

The likelihood of its malignancy depends on the size of a benign neoplasm: the larger the size of a benign tumor, the higher the likelihood of its malignancy.

According to the multiplicity factor, epithelial tumors are divided into:

1. single;

2.multiple:

- group;

- scattered.

3. diffuse (familial) polyposis.

The multiplicity factor is important in the prognosis of the disease - single polyps are rarely malignant (1-4%) and have a more favorable prognosis. Multiple polyps can be compactly located in one of the sections of the large intestine, or they are found 1-2 or more in each section (scattered), malignant up to 20%. Scattered multiple polyps are difficult to differentiate from diffuse colon polyposis. The latter is usually characterized by a massive lesion (there are hundreds and thousands of polyps, and sometimes there are no areas of unaffected mucous membrane at all), and most importantly, it is inherited, that is, it has a family, genetically determined nature and has a significant tendency to malignancy (80-100 %).

Among the epithelial polypoid formations of the colon, there are peculiar, exophytic growing, creeping along the intestinal wall, soft to the touch, formations of a finely lobed structure. Histologically, these are villous adenomas, and the clinical term “villous tumor” can be applied to them.

There are two forms of villous adenomas according to the microscopic picture - creeping and nodular. The nodular form is more common and is located on one of the intestinal walls in the form of a compact exophytic node with a wide and short base or leg. In the creeping form, villous growths are located on the surface of the mucous membrane flat, almost circularly covering the intestinal wall.

Macroscopically, the villous tumor is colored reddish due to the abundance of blood vessels in their stroma. Thin and delicate villi are easily injured and bleed, therefore bleeding in itself is not evidence of malignancy of these formations.

Malignant transformation of a large colon adenoma can be diagnosed with a high degree of probability in the presence of two or more of the following endoscopic signs of malignancy: dense texture of the villous mass, presence of areas of compaction, surface tuberosity, fibrin overlay, surface ulceration and contact bleeding.

It is advisable to isolate the villous tumor of the colon as an independent nosological unit.

Most epithelial neoplasms (polyps) go through successive stages of development from small to large, from a low manifestation of proliferative activity to a greater one, up to the transition to an invasive cancer process.

The appearance of hyperplastic polyps precedes the appearance of glandular (adenomatous) polyps, which, as they grow, can undergo villous transformation, and signs of invasive growth can be detected in the villi. The development of polyps occurs slowly from the simplest structure to sharp degrees of atypia and dysplasia of the mucous membrane, up to the development of cancer, and this process takes at least 5 years, and on average lasts 10-15 years.

Clinical picture

In the majority of patients, benign colon neoplasms are asymptomatic and are found mainly during endoscopic examination. However, when villous tumors reach large sizes (2-3 cm), there may be bloody and mucous discharge, pain in the abdomen and anus, constipation, diarrhea, and anal itching. In giant villous tumors, loss of protein and electrolytes due to overproduction of mucus can sometimes lead to significant disturbances in homeostasis (dysproteinemia, imbalance in water and electrolyte balance, anemia). With them, symptoms of acute complete or partial obstruction (due to intussusception) may appear. The malignancy index of villous tumors is quite high and amounts to 40%.

Diagnostics

In the presence of the above symptoms, it is necessary to conduct a digital examination of the rectum and sigmoidoscopy.

With a digital examination, it is possible to study a section of the rectum up to 10 cm from the edge of the anus. This primary diagnostic method must always be used. It must necessarily precede sigmoidoscopy, since this is a fairly informative way of detecting other diseases of the rectum (hemorrhoids, fistulas, cracks, etc.), the surrounding tissue (cysts and tumors) and the prostate gland in men (adenoma, prostatitis, cancer).

Sigmoidoscopy requires special preparation using cleansing enemas or oral laxatives (Fortrans, etc.). This research method is more informative and makes it possible to detect most of the colon polyps, since more than 50% of them are localized in the rectum and sigmoid colon, i.e., within the reach of the rectoscope (25-30 cm from the edge of the anus). If polyps are found in the rectum or sigmoid colon, a thorough examination of the overlying sections of the large intestine and stomach is necessary, since there is often a combined lesion with polyps of various sections of the gastrointestinal tract. For these purposes, X-ray and endoscopic examinations of the colon and stomach are used.

Irrigoscopy is of great clinical importance, it allows you to diagnose most polyps more than 1 cm in diameter, smaller formations can be detected much less often. Therefore, during routine examinations, it is better to use a colonoscope, with which it is possible to detect almost any formations (less than 0.5 cm in size).

In endoscopic examination of the colon, hyperplastic polyps appear as small (less than 0.5 cm in diameter), slightly rising above the level of the mucous membrane of the formation of a soft consistency and normal color. Often, hypertrophied lymphatic follicles simulate hyperplastic polyps (this is confirmed by histological examination).

Adenomatous polyps are more than 0.5 cm in size and can reach 2-3 cm in diameter, have a leg or be located on a wide base, are similar in color to the surrounding mucous membrane, but have a denser consistency, displace with the mucous membrane, ulcerate and rarely bleed ...

Adenopapillomatous polyps (glandular-villous) usually exceed 1 cm in diameter, have a velvety surface, which gives the impression of a dull color, sometimes appear finely lobed due to an uneven surface, can erode, and the bottom of the ulcers is covered with fibrin, from under which a small amount is released blood.

Villous polyps are large (2 cm or more), can have a thick stem (polyps) or spread over the mucous membrane (tumors), sometimes taking on a creeping character. They occupy a large area, only slightly rise above the surrounding mucous membrane and have no clear boundaries. The color of such formations differs little from the color of the mucous membrane, their surface is velvety and dull, the presence of ulceration allows one to suspect the onset of malignancy. Negative biopsy results cannot serve as evidence of the absence of malignant growth, and the final conclusion is made after the removal of the entire villous tumor.

Treatment

To date, there are no conservative methods for treating polyps and villous adenomas of the colon. The method of treatment of polyposis with celandine herb juice proposed by A.M. Aminev (1965) has not found wide application due to its questionable effectiveness. Its use is impractical, since attempts at conservative treatment only lead to postponement of the operation and the progression of the disease up to the malignancy of the polyp.

Biopsy is not essential in determining the tactics of treating colon polyps. Small areas of a polyp taken for biopsy cannot characterize the essence of the pathological process in the entire tumor. The biopsy-based polyp information is incomplete and may be erroneous. A completely excised polyp is the best material for histological examination.

In modern conditions, only endoscopic and surgical removal of polyps guarantees the success of treatment. The most common surgical procedures for colon polyps and villous adenomas are:

Polypectomy using a rectoscope or colonoscope with electrocoagulation of the leg or polyp bed;

Transanal excision of the neoplasm;

Colotomy or resection of a colon with a tumor;

Transanal resection of the rectum with the formation of a rectoanal anastomosis for circular or almost circular villous tumors of the lower ampullar rectum;

Transanal endomicrosurgical excision of the neoplasm.

All methods of removing polyps are used after special preparation of the colon with laxatives and cleansing enemas. Such preparation also serves to prevent complications.

One of the main complications is bleeding, which can occur up to 10 days after the intervention. The appearance of blood from the anus on the 1st day after removal of the polyp is associated with insufficient coagulation of the vessels of the leg of the polyp. Later bleeding develops as a result of the rejection of the scab, which is most often observed 5-12 days after the operation. Both early and late bleeding can be insignificant, and can be massive, posing a danger to the patient's life. To eliminate this complication, a repeated endoscopic examination is required, during which electrocoagulation of the bleeding vessel is performed. Sometimes such measures do not help, and one has to resort to laparotomy and bowel resection.

The second most frequent complication is perforation of the intestinal wall, which can also occur either during the intervention, or after some time, even several days after it. The emergence of a late complication is explained by a deep burn of the intestinal wall in the area of ​​the base of the removed tumor during electrocoagulation.

If this complication occurs on the intra-abdominal part of the colon, laparotomy and suturing of the bowel wall defect are performed, this section is disconnected from the passage of feces by imposing on the overlying sections of the colostomy, or, if the perforation has occurred high enough, the damaged area is removed in the form of a double-barreled colostomy. In the future, such patients are treated as patients with peritonitis, despite the fact that after preparation there is no content in the intestine and only gas enters the abdominal cavity during perforation. With the availability of modern antibacterial agents and anti-inflammatory therapy, this can be dealt with without complications.

With a favorable postoperative course, the question of closing the colostomy can be raised in 2-4 months.

After removal, all neoplasms of the large intestine are subject to a histological examination in order to be able to judge the degree of epithelial dysplasia or the presence of malignancy.

If adenomatous and villous polyps are found, the patient can be discharged from the hospital under compulsory dispensary observation.

If areas of transition to adenocarcinoma are found, repeated colonoscopy or rectoscopy is necessary with taking material from the bed of the neoplasm for histological or cytological examination. In the absence of adenocarcinoma complexes, the patient can be discharged from the hospital with a mandatory monthly endoscopic examination; if a tumor recurrence is suspected, re-hospitalization, a thorough examination and a decision on further treatment tactics are necessary.

When complexes of malignant cells are found in the material from the tumor bed, a decision is made about a radical operation.

Long-term results of treatment and dispensary observation

Taking into account the possibility of recurrence of benign colon neoplasms and the occurrence of cancer, especially in the first 2 years after surgery, patients should be under constant dispensary observation. After removal of benign polyps, the first examination is performed after 1.5-2 months, then every six months, and in case of villous tumors - every 3 months. within the first year after removal. Further inspection is carried out once a year.

After removal of malignant polyps in the 1st year after the operation, a monthly examination is required, in the 2nd year of observation - every 3 months. And only after 2 years, regular examinations are possible every 6 months.

In the first 2 years after removal of benign neoplasms, relapse was noted in 13% of patients, and new polyps in various parts of the colon - in 7%. Relapses after glandular polyps were observed in 8% of cases, glandular-villous - in 13%, and villous - in 25%. Taking into account that the villous tumor malignancy index is 40%, an increase in the number of malignant neoplasms is possible. The appearance of a relapse is an indication for urgent reoperation.

at the Central Clinical Hospital of the President's Office, endoscopic surgery to remove polyps from the stomach and intestines is performed almost daily. This is a simple, at first glance, procedure has a number of nuances and subtleties of implementation. And these nuances can end up costing you your life. Because in the case of intestinal polyps, everything is important - from the size and morphology (histology) of the polyp found to the experience of the endoscopist and the type of instrument he uses to remove.

When removing polyps, there are certainly certain nuances in order, firstly, to make this manipulation (or, more correctly, a minimally invasive endoscopic operation) safely, i.e. without complications for the patient; and secondly, to avoid re-development (relapse) of the polyp in the same place. Despite the fact that "the abdomen is not cut," the removal of a polyp is considered an operation in medicine. And because it is carried out through an endoscopic apparatus, the operation is easier for patients, but it does not make it easier for the doctor, rather, on the contrary, it takes a lot of experience in diagnostic examinations to move on to endoscopic operations on the intestines. Thanks to the vast experience of our employees, all the subtleties are known to us and, if necessary, are successfully applied.

This is such a common procedure that it is even described on Wikipedia. Therefore, we did not begin to describe in detail its technologies (in the plural, because there are actually several of them), they are widely covered in an accessible form on information sites for patients.

We simply list below the answers to the most frequent questions that our patients ask us over the phone and at consultations.

Heldendoscopic polypectomyin the endoscopy department of the Central Clinical Hospital of the Administrative Department?

Yes, we carry out these procedures. Removing a polyp from the stomach or removing a polyp from the colon it is, in fact, a routine procedure for the endoscopy department of any hospital.

How often do you have this procedure? How long have these manipulations been carried out in the Central Design Bureau of the Administrative Department?

Yes, we do them every day and a lot. Especially often, in comparison with the stomach, we perform the removal of polyps in the intestine (from the colon). As the head institution of the Presidential Administration of Medical Affairs, all the most difficult cases, in particular, creeping adenomas and very large polyps, flock to us. Removal of polyps began almost immediately after the opening of the endoscopy department, i.e. In our department, polyps from the stomach and intestines have been removed for over 30 years.

How to choose the right clinic for safe manipulation?

You do not need to do it in the first medical center that catches your eye. Especially on the principle "come, we will remove and you will immediately go home" - such a rush can lead you in a couple of days with heavy bleeding from the place of removal of the polyp to the nearest emergency hospital, to the very "homeless man" to which you did not want to go under the compulsory medical insurance and, having paid the money, went to a "decent medical center". And the medical center will no longer care - he has already received the money, and you will never exact it back from him - you signed a "consent to the operation", according to which no matter what happens to you after their operation, the medical center has nothing to do with it.

Are large polyps removed? Are there any restrictions on the size of the polyp that can be removed endoscopically?

Yes, we remove polyps of any size, the largest polyp we removed was with a 7 cm head. When removing large polyps, there is always a danger of severe bleeding; to avoid it, special technology and tools are used.

Are complications after removal of a stomach or intestinal polyp possible?

Yes, complications are possible after removal of polyps, which is why we do not recommend carrying them out in medical centers that do not have a hospital. The complication rate differs depending on:

from the size of the polyp - the larger the polyp, the more often complications are observed during the operation (the so-called intraoperative complications) or within a few days after it (postoperative complications in the postoperative period).

from the thickness of the leg - the thicker the leg, the more likely it is that a large blood vessel feeding the polyp passes through it.

from the type of polyp - when creeping adenomas are removed, the risk of perforation (tear) of the intestinal wall increases.

The complication rate in experienced hands usually does not exceed 0.5% for polyps up to 1.0 cm and 3-5% for polyps larger than 1.5-2.0 cm.

An experienced endoscopist can and should cope with any complication arising during the operation.

It is safest to spend the first day after the operation in a hospital under the supervision of the doctors on duty (or, even more correctly, the duty surgeons). Especially when removing polyps from 1.0 cm or more. Therefore, self-respecting clinics, including ours, usually observe patients on the 1st day at their inpatient base - this is a kind of "guarantee" of the clinic for an excellent result without complications.

Is the removal of a polyp from the stomach and removal of a polyp from the colon considered an operation?

Yes it really is endoscopic surgery to remove polyps in the intestines or stomach. To make it clear - a small terminological explanation.

Endoscopic operations are of two types:

Through the skin and abdominal cavity by means of "hard" thin instruments - the so-called laparoscopic

Through natural openings inside the cavity of organs with flexible endoscopes, more precisely through the working channels in these flexible endoscopes, respectively, with flexible and thin instruments.

Price - Removal of a polyp of the stomach or intestines price - 5 thousand rubles,

Polyps, as a rule, do not show any symptoms... Diarrhea causing loss of potassium is rare in villous adenomas. With neuroendocrine tumors of the rectum or sigmoid colon, usually with hormonal activity, clinical manifestations are noted only when metastasis to the liver occurs. 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 intestinal polyp. Apart from the familial syndromes manifested by intestinal polyposis, polyps in most cases are an accidental finding, including during prophylactic colonoscopy.

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

Revealing polyps requires an immediate decision on their treatment. Previously, it was mentioned that small hyperplastic polyps in the rectum are a common finding and can be left behind. This does not exclude the formation of adenoma in the rectum. Differential diagnosis of polyps found in the upper rectum is difficult. For small hyperplastic polyps, unlike adenomas, a fine-grained surface is characteristic, which, when viewed under optical magnification, is dotted with numerous dimples.

Without confidence the fact that the identified formation is a harmless polyp, it should be removed. Multiple small, whitish polypoid lesions in the distal rectum are usually hyperplastic and may be retained.

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

Polyps diameter less than 5 mm can be removed with forceps. The likelihood that the removed polyp contains atypical cells is extremely small. The only exceptions are very small flat or even depressed polyps (adenomas). You can use forceps to measure the size of the polyp. The gap between the jaws when the forceps are open ranges from 2 to 6 mm.

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

Polyps with a diameter of more than 5 mm should be removed with a loop. There are a number of hinge options available that vary in size and shape. The choice of the loop depends on the preference 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 polyphilic 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 from which the loop is made, there is a risk of "cold" removal of the polyp. It also depends on the manipulation 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 monophilic loop is also higher, since it cuts deeper into the tissue. However, there is no scientific or empirical evidence to support this risk.

Regardless of the type loops usually a direct current is fed through it. The loop can function in coagulation and cutting mode, for example ENDO CUT (ERBE, Tübingen). By pressing the yellow pedal, the cutting current is applied, which in the initial phase, when the tissue resistance is still low, causes soft coagulation. As the tissue dries, its electrical resistance increases, causing the voltage to rise until an arc of light is detected by the system. The cutting phase lasts, depending on the system used in the machine, 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 ENDO CUT setting 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 manipulate not the “Fast coagulation mode” knob, but mainly the “Effect” knob of the ENDO CUT mode. Turning the "Effect" knob to graduation "4" means a decrease in the cutting current in favor of the coagulation current.

When removing small polyps the initial phase of the cutting mode is important (the parameters of which do not change), since these polyps are usually cut off at the very first current impulses. When coagulating, the loop must be kept parallel to the intestinal wall in order to better cover 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 also not very high, since in this case part of the polyp may remain unremoved. Polyps located in the fold of the mucous membrane should be especially carefully removed. Grasping the base of the polyp in a loop, it is pulled up and cut off. Small polyps, after excision, can be retracted into the working channel of the colonoscope. In this case, a filter (polyp trap) should be installed 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.

Aspirated polyps often obstruct the working channel in the tube of the colonoscope. In such cases, it is recommended to inject 20 ml of water into 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 the colon adenomas. Cutting off the adenoma is carried out at the level of the basal third of its leg. Ideally, a pedunculated polyp can be grasped and removed.

Polyps may manifest as intestinal bleeding. However, the macroscopic picture cannot be used to judge the degree of risk of bleeding from a particular polyp. Prevention of bleeding, for example, by applying a clip "Hamoclip" or injecting a solution of epinephrine at a dilution of 1:10 000 into the base of the polyp, is usually not required. When removing a polyp, small vessels should be carefully coagulated. Exceptions are possible, for example when polypectomy is performed on a patient taking acetylsalicylic acid. In some cases, depending on the morphological characteristics of the removed adenoma, one or more clips are applied.

At removing very large pedicle adenoma, the risk of complications is especially high. This is due, on the one hand, to the abundant blood supply to such an adenoma, and on the other, to the use of high-frequency current. If, due to the significant density of the base of the polyp, it is impossible to reliably apply clips before its removal, then the polyp is removed using an “Endoloop” loop. This loop remains in the intestine after application. The effect of the method can be judged immediately after the application of such a loop. The cessation of blood flow to the polyp leads to its cyanosis. When removing the polyp, make sure that the loop wire is positioned over the Endoloop hemostatic loop when applied. The question of whether to apply 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 after cutting off the polyp can slip off. This can also happen some time after the polyp is cut off.

The risk of removal is also associated with bridging. They occur when a 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 removing, pull it back 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 the excessive thermal effect can cause extensive destruction of the base of the polyp.

The macroscopic picture with adenoma is different diversity... In each case, it is necessary to get a clear idea of ​​the shape of the adenoma before the intervention. This is facilitated by manipulations such as displacement of the adenoma with a colonoscope or some instrument, such as a tightened wire loop, and insufflation of varying volumes of air. It is especially important to clarify the localization of the adenoma in relation 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 deleting " 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 into the base of the polyp reduces the risk of perforation.

For removing polyp on a broad basis, preference should be given to a monophilic 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 a polyp residual tissue. If present, remove it using the same wire loop.

The thinnest wall of all parts of the large intestine, the cecum has, therefore, the risk of its perforation is especially high. Even when removing small polyps that have formed in the cecum, you should resort to injecting sodium chloride solution into the base of the polyp. This 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 injected saline solution of sodium chloride. It allows you to better identify structures located under the mucous membrane and separated from it by the muscle plate, as well as to identify the residual tissue of the polyp.

For removing polyps on a wide leg and villous adenoma, an injection into the base of saline sodium chloride is recommended. Infiltration with a solution expands the submucosal space and facilitates the separation of the mucous membrane from the muscle plate. 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 injecting adrenaline solution into the bleeding base of the polyp. It should be distinguished from an injection, which is performed for prophylactic purposes and the effectiveness of which has not been proven. The injection can be repeated as needed. The polyp is removed in small pieces, taking care not to leave residual tissue. The remaining fragments are removed with forceps, grasping these fragments to the full depth of the branch. If the wound surface after cutting off the polyp is large, then you can apply clips "Hamoclip"; for a better fit of their ends, air should be sucked out of the intestine.

When deleting polyp chipping ("piece by piece") does not matter how many fragments to divide it. You just have to try so that these fragments are not too large. Removing the polyp in small pieces minimizes the risk of bowel perforation.

Removal of villous adenomas fraught with the risk of not only bowel perforation and bleeding, but also the development of relapse when leaving residual polyp tissue. Removing recurrent polyps is difficult because of the scarring that forms after the first intervention. Therefore, after removing the polyp, it is necessary to carefully check the wound surface and the edges of the mucous membrane to make sure that there is no remaining polyp tissue. This task is facilitated by the use of high-resolution endoscopes (structural image enhancement). Remnants of the polyp, revealed during examination of the wound surface and the edges of the mucous membrane, should be removed with a wire loop or forceps. Using argon plasma coagulation to treat the edges of the base of the polyp, coagulate the wound surface itself (the muscle plate of the mucous membrane). Coagulation, according to the literature, reduces the risk of recurrence, but whether it should be preferred to removing the remnants of the polyp with forceps is not yet clear.

When describing removal techniques for large, and especially flat, polyps after injection into the base of saline solution of sodium chloride in the publication uses the concept of "mucosectomy". This is an endoscopic mucosal resection, which is often performed in the upper gastrointestinal tract, mainly using a special endoscope attachment (ligature mucosectomy). When applied to the colon, this procedure is called hydraulic dissection polypectomy; the name adopted in the English-language literature is Saline-assisted Polypectomy. Mucosectomy with the help of a nozzle is performed mainly with lesions of the rectum, since the more proximally located parts of the intestine have a thin wall. Similarly, during submucosal dissection (endoscopic submucosal dissection), a saline solution is injected into the submucous base 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, unlike the one described above, takes more time and more often causes complications, and if in diseases of the upper gastrointestinal tract, and in particular the stomach, submucosal dissection has established itself as a method of treatment, 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%. Factors that are associated with high risk include:
taking anticoagulants and, to a lesser extent, antiplatelet agents;
large size of adenoma (more than 2 cm) on the leg;
proximal localization of the adenoma;
insufficient experience of the doctor.

Large sessile adenomas("Sedentary") are also associated with an increased risk, as are polyps with dense stalks. 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 at a dilution of 1:10 000. For polyps, the diameter of which exceeds 1 cm, injection of an adrenaline solution into its base reduces the risk of bleeding. However, the works confirming the effectiveness of this method are based on an insufficient number of clinical observations, and the need to add adrenaline to the injected solution has not been proven at all (S.-H. Lee, World J. Gastroenterology 2007). It also remains unclear why injection of saline sodium chloride solution alone is effective. The explanation, apparently, lies in the fact that it reduces the resistance of the tissue and thereby lengthens the initial cutting phase when applying a high-frequency electric current. It is also not completely clear how the “Endoloop” loop has a hemostatic effect when removing large polyps (more than 2 cm in size) on the pedicle. The results of a comparative study of the effect of diluted (1:10 000) and concentrated solution of epinephrine 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, although this method of stopping bleeding seems to be the most commonly used.