Cap-Assisted Endoscopic Mucosal Resection Effective for Flat and Fibrotic Colorectal Polyps

COMMENT

I’ve used the cap technique for flat and fibrotic disease in colorectal EMR for more than a decade and in hundreds of cases, with only a single type 3 muscle injury. This lower risk of injury is almost certainly because I don’t put the cap out as far as that demonstrated in the photos from the current study. Cap-assisted EMR is more efficient than avulsion for removing flat and fibrotic disease if there is a larger surface area to remove, but avulsion is generally more effective than EMR because disease that resists removal with the cap technique will almost always submit to avulsion.

Available evidence suggests that ablation of visible polyp tissue should be abandoned in favor of the cap technique or avulsion, as ablation is associated with a higher recurrence rate. Colonoscopists are sometimes confused by the admonition to avoid ablation for visible residual tissue because ablation of the normal-appearing margin with snare-tip soft-coagulation thermal injury is advocated to reduce recurrence rates. However, ablation of visible residual polyp tissue is not recommended, whereas ablation of the normal-appearing margin after complete resection by snaring with or without avulsion is highly recommended. The two concepts regarding ablation must not be confused.