Endoscopic Mucosal Resection and Argon Plasma Coagulation for Large/Flat Colonic Polyps

Endoscopic Mucosal Resection and Argon Plasma Coagulation for Large/Flat Colonic Polyps

This information has been produced to provide you with details about a procedure
called ‘Endoscopic Mucosal Resection’ (EMR). This procedure is used to remove
large polyps. This information aims to answer any concerns that you may have.
Please do not hesitate to ask a member of staff if you have any further questions or
concerns.

Why have I been referred for EMR?
We have found a polyp in your bowel. Some polyps are straight forward to remove
and are removed at the time of your initial endoscopic examination, but in your case
the polyp is larger than average and requires the ‘EMR’ technique. This is generally
considered the simplest and safest method for removing this sort of polyp. The aim of
this technique is to remove the polyp fully, safely by using techniques to reduce the
risks of complications like bowel perforation, bleeding and recurrence of polyp and to
detect if there are any cancer cells in the polyp.

Benefits of removing such large polyps include:

• Reducing risk of cancer development in the polyp
• Diagnosing cancer in the polyp
• Improving symptoms caused by a polyp

Before your procedure
You will receive the standard patient information and medication for bowel washout
before the test. This is the same information and bowel preparation that you will have
had for your previous colonoscopy procedure. Please take time to read the
information and follow the instructions provided to you by the Bowel Cancer Screening
Team.

If not already discussed with you, please contact the Bowel Cancer Screening Office
immediately if you:

• Are a diabetic
• Have suffered a heart attack within the last 3 months
• Are having kidney dialysis
• If you are taking warfarin or acenocoumoral or clopidogrel (Plavix®) or
  dipyridamole (Persantin® or Asasantin®) or Aspirin or other anti-coagulants
  (Dabigatran or Pradaxa®,Apixaban or Eliquis®, Rivaroxaban or Xarelto®)
• You will need to stop Iron tablets 1 week before the procedure

During your procedure
From your point of view, you may notice no difference from your previous
colonoscopies. More general information about having a colonoscopy is given in the
separate leaflet which you will receive. The EMR procedure can take longer than a
standard colonoscopy – this can vary depending on the size and position of the polyp
but can take up to 90 minutes. A sedative injection can be given to help you relax
during the test. The test can be stopped at any time on your request, though medical
advice would be to attempt to remove the polyp fully at a single session as repeat
procedure can increase risk of complications.

During the procedure, the endoscopist will find the polyp which has previously been
detected in your bowel, then assess whether EMR is the best way to remove the polyp
and if so, will attempt to remove the entire polyp using the endoscope equipment. The
diagram below illustrates the technique.

A special needle is passed through the colonoscope and inserted under the base of
the polyp. Fluid is injected through the needle to raise the polyp away from the lining
of the bowel wall. A wire snare is then passed through the scope and positioned
around the raised polyp. The snare is pulled tight, and an electric current is passed
through the snare which cauterises any blood vessels as the polyp is cut off. If the
polyp is very large, it may be removed in several pieces in the same way.

Argon Plasma Coagulation (APC) may be used to cauterise the edge and base of the
area of polyp removal to reduce the risk of bleeding and polyp recurrence.
Endoscopist may mark the area of the removed lesion with ink (tattoo) so that when
follow-up endoscopy is performed, he or she can be sure the lesion was removed
completely.

What are the risks of EMR & APC?
EMR carries the same risks of standard colonoscopy. These are explained in the
colonoscopy information leaflet. However, because of the technical nature of EMR,
the risk of perforation or bleeding is significantly higher (although still uncommon). In
general, EMR is considered the safest technique for removing this sort of polyp.

The main risks are:

Perforation – this means tearing a hole in the bowel. For EMR, this occurs about one
in less than 50 to 100 patients (1 to 2 %) with the highest risk when removing large
polyps from the right hand side of your colon. This will necessitate hospital admission.
Occasionally perforations heal with antibiotics and sometimes they can be treated
with the endoscope by using metal clips. However usually an emergency operation is
required. As with any bowel operation, a stoma (bag on your abdomen) is occasionally
required, although this would usually be temporary. Perforation of bowel can occur or
come to light up to a week after the procedure

Bleeding – bleeding may occur once in every 50 or 100 patients (1-2%). Sometimes
bleeding occurs during the test, but it can occur up to 14 days after the procedure. If
bleeding does occur, it often stops on its own. However, very occasionally it requires
a blood transfusion or further endoscopic procedure. Very rarely an emergency
operation may be required to stop it. As with any bowel operation, a stoma (bag on
your abdomen) is occasionally required, although this would usually be temporary.
Serious complications related to bowel perforation and bleeding carry a small risk of
mortality.

Incomplete removal – sometimes the endoscopist cannot remove all the polyp for
technical reasons – if this happens, a repeat endoscopic procedure might be planned
for a later date or may refer you for an elective operation.
Rarely, occult cancer may be present in the polyp, and this might be missed if all the
removed polyp is not retrieved for microscopic examination. If a cancer is detected in
the polyp removed on microscopic examination, you will be referred for consideration
of further investigation and treatment including surgical bowel resection.

What happens if the endoscopist does not think that EMR is possible?
In this case, the Endoscopist and Specialist Screening Practitioner will discuss
whether you need to have an operation to remove the polyp.

Are there any other ways of dealing with my polyp other than EMR?

1. Do nothing – leave the polyp where it is. However, this is usually not advisable
   as large polyps often turn cancerous if they are left to grow or there may be
   occult cancer already present in the polyp
2. Remove the polyp by having a major operation on the bowel. Although usually
   a straightforward procedure, this carries the risk of the general anaesthetic and
   surgery (such as infection) and usually leaves you with a scar on the abdomen
   (tummy). Sometimes this can require a stoma (bag on your abdomen), although
   this may only be temporary.

After The procedure
You will usually be ready to go home approximately 1 to 2 hours after the procedure
has ended, though sometimes we might admit you to hospital for overnight
observation. Please bring an overnight bag with you in case this is recommended.
Please ensure that a responsible adult can collect you from the department, take you
home and stay with you for 24 hours.

Before you are discharged you will be given a copy of the report and clear details
concerning follow up arrangements and aftercare information. A full report will be sent
to your GP and referring hospital consultant. You will be given contact details in the
event of any complications that may occur. The polyp is usually retrieved during an
EMR procedure and sent to the pathology laboratory for further analysis. It can take
up to 2 weeks before a result is available. Your Specialist Screening Practitioner will
then be in touch with you regarding these results. Sometimes decisions about further
treatment can only be made once these results are available.

Please avoid doing any strenuous physical activity, constipation and straining, lying
or travel abroad for 2 weeks. After 2 weeks the chance of any complication is less
than 1 in 1000.

The following signs or symptoms may indicate a serious complication from
endoscopic mucosal resection:

• Fever, Chills ,
• Sustained Vomiting ,
• Black or Bright red blood in the stool,
• Chest or severe abdominal pain, new onset Shortness of breath, Fainting

You need to contact hospital or GP or attend emergency department with a copy of
your report in the event of any of the above symptoms.

Follow-up exams
Typically, a follow-up exam is performed three to 12 months after your procedure to
be sure the entire lesion was removed. Depending on the findings, your Specialist
Screening Practitioner will advise you about further examinations.

CONTACT TELEPHONE NUMBERS:

If you have any specific concerns about your procedure, that you feel have not been
answered and need explaining, please contact the following:

Worcestershire patients:

Bowel Cancer Screening Team

Office – 01905 733 875

Alexandra Hospital Redditch

Booking Office – 01527 505751

Endoscopy Nursing Staff – 01527 512014

Kidderminster Hospital

Booking Office – 01562 826328

Endoscopy Nursing Staff – 01562 513249

Worcestershire Royal Hospital

Booking Office – 01905 760856

Endoscopy Nursing Staff – 01905 733085

Herefordshire patients:

Hereford Hospital
Endoscopy Nursing Staff – 01432 355444

Reference:
EMR and APC for large/flat colonic polyps Version 3 Chesterfield Hospital NHS Foundation Trust

If your symptoms or condition worsens, or if you are concerned about anything,
please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you
and your loved ones. If you have any questions or concerns, please do speak with a
member of staff on the ward or in the relevant department who will do their best to
answer your questions and reassure you.

Feedback
Feedback is really important and useful to us – it can tell us where we are working well
and where improvements can be made. There are lots of ways you can share your
experience with us including completing our Friends and Family Test – cards are
available and can be posted on all wards, departments and clinics at our hospitals. We
value your comments and feedback and thank you for taking the time to share this with
us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the
nurse in charge or the department manager in the first instance as they are best placed
to answer any questions or resolve concerns quickly. If the relevant member of staff is
unable to help resolve your concern, you can contact the PALS Team. We offer informal
help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf,
if you feel unable to do so, to resolve your problems and where appropriate refer to
outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate
your concerns. You can make a complaint orally, electronically or in writing and we can
advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: [email protected]

Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please
be aware that you may need to leave a voicemail message, but we aim to return your
call within one working day.
If you are unable to understand this leaflet, please communicate with a member of staff.

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