1.Indications for endoscopic treatment.
(1) Tender polyps and adenomas of various sizes.
(2) Non-tipped polyps and adenomas less than 2cm in diameter.
(3) Scattered and multiple polyps in the digestive tract.
2. Contraindications to endoscopic treatment.
(1)Those with contraindications to gastrointestinal endoscopy.
(2) Non-tipped polyps and adenomas larger than 2 cm in diameter?
(3) Polyp morphology with malignant change by pathological examination.
(4) Multiple polyps leap densely in a certain area.
3, the choice of endoscopic treatment methods.
(biopsy forceps removal, hot biopsy forceps removal, local injection of sclerosing agent, microwave coagulation, argon knife, skin ring ligature, high frequency electrodesection, EMR, a number of integrated).
4, Preoperative related preparation.
① Pre-operative discussion: for thick-tipped giant polyps, EMR, non-tipped broad-based polyps, special sites such as middle esophageal polyps, descending duodenal polyps, hepatosplenic flexural polyps of the colon and other difficult polypectomy treatments with higher risk, pre-operative discussion must be organized by the chief of the department. Before the discussion, we need to ask about the medical history, physical examination, treatment purpose and requirements, relevant laboratory tests such as blood routine, coagulation four, histological examination or imaging data. The main contents of the discussion are: indications and contraindications for treatment, treatment modalities, risk and efficacy estimation, and composition of surgical staff. A preoperative plan must be developed for major and difficult procedures.
②Information: Sign the informed consent form for endoscopic treatment. To inform the present-day methods of GI polyp treatment and their comparison; to specifically inform the possible complications of polyp treatment (mainly bleeding, perforation, multiple endoscopic treatments required for one time not completely eradicated, recurrence, preoperative related symptoms some of which are not caused by polyps may not be eliminated or even aggravated in the short term after endoscopic treatment, treatment cost, etc.).
③ Make adequate preoperative preparation, such as blood preparation, related examination, and even surgical preparation.
5.Intraoperative quality control
(i) Clearly define the division of labor and responsibilities between the main surgeon and assistants (1 or 2), cooperate with each other and do their respective duties.
(b) Strictly follow the medical routine to improve the operation skills and reduce complications as much as possible. If an “accident” occurs during the operation, the superior physician and the chief of the department should be asked to come to the scene to provide guidance and assistance in dealing with the situation.
(c) After the treatment is completed, check the treatment effect and whether there are complications such as bleeding and perforation.
(iv) For high-risk groups, do electrocardiogram, pulse, blood pressure and oxygen saturation monitoring.
(6) Write standardized postoperative endoscopic reports.
Observe closely for complications such as bleeding, perforation and infection. For pathological examination, see the pathological report before discharge.
I. Operation skills
(A) Non-tipped polyps
1.Diameter less than 0,5cm can be removed by microwave, argon knife or hot biopsy forceps or in order to get pathological diagnosis, it is better to biopsy first and then electrocoagulation cauterize or microwave treatment.
2, diameter less than 2cm polyps: trap polyps slightly above the base is the best part of the polyp removal, gently close the trap loop slightly tightened, slightly raised to the cavity, so that the formation of the base with the “tip” when the electricity, first electrocoagulation and then electrodesiccation (electrocoagulation, electrodesiccation alternately applied 3-4 seconds / time) or the use of mixed current, note that electrocoagulation can not be excessive The electrocoagulation should not be excessive, so as not to cause gastrointestinal perforation. For insurance purposes, saline can be injected at the base first to form a subtibial at the base, and then electrosurgery. Can also be ligated treatment.
3, endoscopic excision of polyps larger than 3 cm in diameter is prone to bleeding and perforation, which is a relative contraindication, in recent years, due to the improvement of the method can also be excised endoscopically, generally do EMR. but still need to be prepared for surgery, and explain the dangers to the family, once there are serious complications that surgical treatment.
(B) Tender polyp
1, long-tipped polyps are generally trapped in the center of the tip, so that the residual tip retains a certain length, lift the polyp so that it hangs in the intestinal cavity, the polyp removal end can not touch the opposite or next to the intestinal wall, so as not to cause damage to the intestinal wall. Most of the long tissues are normal intestinal mucosa, formed by the gravitational effect of the polyp itself and the pulling of intestinal peristalsis, not the polyp tissue, the residual tissues after polyp removal will recover flat in 3 – 5 days, retaining the proper length of the tissues will help to reduce complications, such as perforation and bleeding.
2, Short-tip polyp collars should be placed close to the neck of the polyp and then tightened, once tightened, electricity should be passed for coagulation and cutting.
3, thick-tipped polyps and thin-tipped polyps in the trap tightening should master the appropriate strength, and pay attention to the time of electricity. The fine tip should be electrically coagulated once it is tightened to avoid bleeding caused by mechanical cutting, and generally the coagulation current can be used. Thick-tipped polyps usually have thicker blood vessels located in the center of the tip to supply the tumor.
II. Complication prevention and control
(A) Bleeding
According to the time of bleeding, it can be divided into immediate bleeding and late bleeding. Immediate bleeding refers to the bleeding of the stump that can be seen endoscopically during the operation or after the polyp is removed. If the bleeding occurs within 24 hours after the polyp is removed, it is called early bleeding, which occurs for the same reason as immediate bleeding. Late bleeding refers to bleeding that occurs 24 hours after polyp removal, often 3-7 days or up to 2 weeks after surgery, due to the formation of ulcers and bleeding when the stumps are scabbed off.
1.The causes and prevention of immediate bleeding
(1) mechanical cutting operator and assistant cooperation for tacit understanding. Resulting in failure to electricity that tighten the capsule caused by excessive force.
(2) the type of current or power improper too much use of electric cutting current due to coagulation is not enough to cause immediate bleeding. Current power is too small or too large can cause insufficient coagulation and bleeding, the former is actually the same as mechanical cutting, the latter because the role of coagulation has not yet been quickly cut down the polyps caused.
In order to prevent the occurrence of the above reasons, the main thing is that the operator and the assistant need to cooperate tacitly, and if necessary, the operator can master the tightening of the collar and control the current, and the collar should be tightened slowly and with moderate force. The size of the high-frequency current should be selected to be appropriate, and the operation should alternate between electrocoagulation and electrocutting, and generally only electrocoagulation can be used for thin-tipped polyps. The electrocoagulation should be sufficient before electrodesection or mixed current is used. Especially for thick-tipped polyps or polyps without a tip, with thicker blood vessels in the center, the cut should be fully coagulated and then electrocuted, so repeatedly until the polyps fall off.
2. Causes and prevention of delayed bleeding
(1) Low current power, excessive electrocoagulation caused by too long electrocoagulation time, and too large and deep stump ulcers.
(2) Systemic diseases, such as arteriosclerosis or coagulation dysfunction, incomplete intravascular thrombosis after scab shedding.
(3) Excessive physical activity after surgery, dry stool, eating rough food to make the scab fall off prematurely and damage the wound surface and bleeding.
(B) Perforation
Perforation can occur intraoperatively or several days after surgery, and the common causes are.
1, thick-tipped or non-tipped polyps are cut too close to the intestinal wall.
2.The polyp is not gently lifted into the lumen to form a tipped pseudo-tip when energized.
3.The normal mucosa is mistakenly circled in the operation, and the trap wire is in contact with the surrounding intestinal wall when energized or the normal mucosa is in contact with the wire when energized by gastrointestinal peristalsis.
4, the trap wire is not tightened when energized or the current is weak, resulting in too long energization time, making the stump burn too deep.
The consequences caused by perforation are serious and should be detected and properly treated as early as possible. To prevent perforation of the digestive tract, in addition to paying attention to the clarity of the intraoperative field of view, the size of the current, and the position of the trap, close observation is required after the operation, especially for 3 days after the operation.
Third, postoperative treatment
1.Esophageal polyps should be fasted for 24 hours after surgery, and liquid diet for more than 3 days, and gastrointestinal polyps can be fasted for 12-24 hours after surgery according to the situation, and less slag diet for 3 days.
2.Bed rest for 2-3 days after surgery, avoid heavy physical labor for 1 or 2 weeks.
3.Postoperative medication: upper gastrointestinal polyp removal according to peptic ulcer medication for 2 weeks (acid suppressant + mucosal protectant), lower digestive tract to keep the stool open, taking laxatives, mucosal protectants and antibiotics; according to the situation can be applied to hemostatic drugs as appropriate.