Mr. Shen, 72, who lives in Xuhui District, has been sleeping badly and worrying a lot recently because of a small intestinal polyp. Recently, the major communities in Shanghai carried out colon disease screening, and the stool test was positive for occult blood twice. The doctor told Mr. Shen that it was a polyp, mostly benign, and that it could be removed under colonoscopy for pathological diagnosis. So Mr. Shen received the polyp removal under colonoscopy in the outpatient clinic very smoothly. However, the biopsy pathology report three days later made Mr. Shen a little nervous. The larger polyp was reported as “villous adenoma, local cancer possibility”.
With anxiety, Mr. Shen consulted me, and after carefully reading the colonoscopy report and pathology description, I told Mr. Shen that although the colon polyp he had had early cancer, the lesion was still limited to the mucosal layer of the intestine, and the resection margin was negative, so there was no risk of incomplete resection or metastasis to the lymph nodes, so he could not worry about it, as long as he remembered to review the colonoscopy after one year. After I explained this, the stone in Mr. Shen’s heart finally fell to the ground.
With the change of diet structure, the incidence of colorectal polyps is increasing, and if these polyps are not removed before it is too late, some of them will gradually turn into intestinal cancer. With the promotion of Shanghai’s bowel cancer census, many people have undergone colonoscopy under the advice of doctors, and even found many bowel cancer patients. The situation like Mr. Shen is very common. After the polyp is found by colonoscopy, either the patient is torn between surgery or colonoscopy, and some patients with early cancer reported by pathology biopsy after colonoscopy are very torn between clean cut and whether it will recur and metastasize, and they have a lot of worries. Especially in recent years, with the rapid development of endoscopic technology, the technology of colonoscopic treatment has advanced rapidly, and the removal of many polyps and even early tumors under endoscopy is no longer a technical problem. The problem lies in which lesions are suitable for endoscopic resection, which are recommended for surgical resection, and which are recommended for additional surgery after endoscopic resection according to the pathological results, and with the continuous development and popularity of endoscopic technology, these questions will become more and more patients’ mind “nagging”.
Colorectal polyps is actually a general concept of morphology, a general term for raised lesions that occur in the intestinal mucosa. There are many types of polyps, such as hyperplastic polyps, inflammatory polyps, childhood polyps, adenomas, familial polyposis, and other rare types. Most colorectal polyps have an insidious onset without any clinical symptoms, while a few manifest as changes in stool habits, blood and mucus in stool, thin stools, and increased frequency. Some typical extra-intestinal symptoms often suggest the possibility of polyposis, and some patients often visit the doctor because of extra-intestinal symptoms, which should not be ignored. Since the disease has few clinical symptoms, it is easy to ignore or miss the diagnosis. Therefore, the diagnosis of colon polyps should firstly raise the awareness of the disease, and anyone with unexplained blood in stool or gastrointestinal symptoms, especially middle-aged and older men over 40 years old, should pay attention to further examination in order to improve the detection rate and confirmation rate of colon polyps.
Whether to choose endoscopic removal or resection after polyp discovery is a very specialized issue, which requires a specialist to make a decision based on the size, location, morphology of the polyp and the patient’s age and systemic condition, usually, smaller or tipped polyps, polyps considered benign by naked eye, lesions that are suspected or confirmed to be early cancerous but are confined to the mucosal layer by ultrasound endoscopy, lesions that are clearly cancerous but are Endoscopic local excision can be chosen for cases where the patient is too old and frail to tolerate surgery, etc. If the lesion is benign, regular follow-up colonoscopy can be performed. However, if the lesion is cancerous, it brings the so-called “kinks” mentioned above. This requires a three-way discussion between the endoscopist, pathologist, and colorectal surgeon to analyze the type of pathology, depth of infiltration, and basal and circumferential margins. It is worth noting that most of the electrosurgical instruments used for colonoscopic resection are electrocautery type, which sometimes causes difficulties in pathological judgment. If the lesion reaches the submucosa, what is the specific depth of the submucosa (professionally it can also be divided into three layers), which is related to how much chance of lymph node metastasis of the tumor and whether additional surgery is needed. Therefore, it is controversial whether endoscopic resection is suitable for the so-called “early cancer” that infiltrates into the submucosa. Because it will make a small number of patients with lymph node metastasis “under-treated”, and then go for “salvage surgery” after later recurrence, the result will be much worse. How to avoid over- and under-treatment is a matter of both technical and philosophical factors, and requires a very specialized physician to make individualized treatment decisions, taking into account the patient’s age and physical status.