Endoscopic Mucosal Resection (EMR)

Why have I been provided with this leaflet?

Previous tests have shown you have a “polyp” (wart-like growth) in your large bowel.  Due to the position and/or size of the polyp, a procedure called EMR (endoscopic mucosal resection) is required in order to remove it. This leaflet explains to you more about your polyp and what is involved in its treatment.

What is a large bowel polyp?

A polyp is a small wart-like growth that sometimes forms on the lining of the bowel. Most polyps do not cause any symptoms but in some cases they can cause bleeding or a change in bowel habit.

Most polyps are harmless but larger polyps have a small chance of containing cancer cells and if they are left to grow, can soon become cancerous.

The majority of polyps can be removed by using a camera (“endoscopy”, “colonoscopy” or “flexible sigmoidoscopy”) test. By removing the polyps, your risk of developing bowel cancer is greatly reduced.

Large (2cm or bigger) polyps can be more difficult to remove, but we can still remove most of these polyps as part of your endoscopy. However, occasionally it is not possible to remove some polyps this way and a surgical operation may be required.

Why have I been referred for an EMR procedure?

Your polyp is either larger than average, or in a difficult position within your bowel. Having an EMR (endoscopy) procedure has been deemed by an experienced endoscopist (a specialist doctor or nurse trained in performing endoscopy procedures) as potentially the best option for your polyp to be successfully removed.

What is an EMR procedure?

EMR is usually carried out as part of a camera-based procedure (“colonoscopy” or “flexible sigmoidoscopy”). You will receive a separate information leaflet regarding these procedures and should read these leaflets before preparing for your procedure.

As outlined in these leaflets, you will receive medication for bowel washout before your procedure and may choose to receive sedative drugs during the test. Please take time to read and follow the instructions carefully.

The EMR procedure can take longer than a standard colonoscopy; the extra time will vary depending on the size and position of the polyp, from ten minutes to over an hour.

The specialist endoscopist will first find the polyp which has previously been detected in your colon. They will then assess whether EMR is the best way to remove the polyp and if so, will proceed with the polyp removal.

Removal of the polyp is painless, although there can be some discomfort from the gas that needs to be inserted into the bowel to give good views of the polyp.

1. The polyp is identified with the colonoscope and assessed for removal by EMR.
   
2. A special needle is passed through the colonoscope and inserted under the base of the polyp. Fluid is injected under the polyp producing a bleb of liquid which lifts the polyp off the lining of the bowel.
   
3. A wire snare (or lasso) is passed around the raised polyp. The lasso is pulled tight and an electric current is usually passed through the snare which cuts the polyp off and cauterises any blood vessels. If the polyp is very large, it may be removed in a number of pieces in the same way.
   
4. Once the polyp has been removed, it is retrieved so that it can be sent to the pathology lab for further analysis.

What are the benefits of removing the polyp?

Removal of the polyp will reduce your risk of developing bowel cancer and may treat any symptoms that are being caused by the polyp.

What are the risks of EMR?

EMR carries the risks of standard colonoscopy. These are explained in the colonoscopy information leaflet. However, because of the size and position of your polyp, the risk of perforation or bleeding is higher (although still not common). In general, EMR is considered the safest technique for removing large polyps.

The main risks are:

• Perforation. This means a tear in the bowel wall. For EMR, this occurs about once in every 100 patients. Occasionally, perforations heal with antibiotics and bowel rest, and sometimes they can be treated with the endoscope.

However, an emergency surgical operation is required about half of cases. As with any bowel operation, a stoma (bag on your abdomen) may be required, although this would usually be temporary.

• Bleeding. Bleeding may occur in about 1 in 30 people, with the highest risk when removing larger polyps from the right side of your colon.

Sometimes bleeding occurs during the test, but it can also 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 endoscopies. Very rarely, emergency surgery may be needed to stop it.

If you take any drugs to thin your blood, you will usually be asked to stop these temporarily prior to EMR. If you usually take Warfarin, we may arrange for you to have daily injections of heparin instead. This will help to reduce the risk of bleeding.

Most patients do not develop problems while they are not taking their blood thinning medication, however there is an increased risk of developing blood clots or having a stroke during this time. This is something you may wish to discuss with the endoscopist prior to your procedure.

• Incomplete removal. Sometimes the endoscopist cannot remove the entire polyp for technical reasons (e.g. scarring underneath the polyp). If this happens, you may need a further attempt using the endoscope, or an operation that will be planned at a later date.

• Recurrence. Even when all the parts of the polyp seem to have been removed, the polyp can grow back. This is called recurrence. Depending on the nature of the polyp this can be happen in up to 20 in 100 patients within a year of initial removal. This is why we arrange for routine endoscopy check-ups and usually this can be dealt with during those check-ups.

Sometimes, the recurrence may be persistent and in 2 – 5 out of 100 cases, it may mean a surgical operation is needed to remove the polyp completely.

You may wish to discuss the risks again with the doctor/nurse who will seek your consent prior to the examination.

What happens if the endoscopist does not think that EMR is possible?

In this case, you will usually be seen in clinic and the clinician will discuss whether an operation would be a better way to remove the polyp.

Are there any other ways of dealing with my polyp?

There are two main alternatives to having an EMR:

1.         We could decide to leave the polyp as it is and do nothing. This option may be preferable in patients who have significant health problems. The rationale being that the polyp is unlikely to cause problems in their remaining lifetime.

2.         The polyp could be removed by having an operation on the bowel. This is usually a straightforward procedure (removing the section of bowel where the polyp sits and joining the ends together again).

This may be an open or key-hole procedure but carries the risks of general anaesthetic and surgical complications such as infection and delayed healing, which are usually higher than the endoscopy risks.

There is a risk that the join in your bowel may leak, requiring further surgery. It will also leave you with a scar on your abdomen.

Sometimes, surgery can require the formation of a stoma (bag on your abdomen), although this may only be temporary. The risks of surgery may be considerably higher if you have other medical conditions and does include a risk to your life.

There may be other options available to remove the polyp. These will be discussed with you before you decide what is the best option for you.

Does it hurt and will I be in pain?

The examination may result in some abdominal discomfort as the scope is moved around your bowel. The procedure is longer than an initial colonoscopy. You may need to lie in a particular position for up to 2 hours to allow the polyp to be removed safely. Any discomfort should begin to settle once the procedure is finished.

How will I know the results of my test?

The endoscopist performing the procedure will often be able to give you some results straight after the procedure. Before you are discharged, you will be given clear details concerning follow up arrangements and aftercare information.

A full report will be sent to your GP and/or hospital consultant. You will be given contact details in the event of any complications that may occur.

The polyp is usually sent to the pathology laboratory for further analysis. It can take up to 3 weeks before this result is available. Your consultant will then be in touch with you regarding these results. Sometimes decisions about further treatment can only be made once these results are available.

You will usually be sent a further colonoscopy appointment around three to four months after the initial EMR to check the entire polyp has gone.

References

Rutter MD, Chattree A, Barbour JA, et al British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps. Gut 2015;64:1847–73.doi:10.1136/gutjnl-2015-309576

Further information

If you wish to discuss any of this information further, please contact the endoscopy unit:

University Hospital North Tees

Telephone: 01642 624387

University Hospital Hartlepool

Telephone: 01429 522536

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