Removing a Large Flat Colon Polyp by EMR without Surgery

By Jim Sease — 2/1/2012 (revision)

Introduction

Large flat villous adenoma colon polypA doctor at California Pacific Medical Center Interventional Endoscopy Services used endoscopic mucosal resection (EMR) to remove my large flat colon polyp endoscopically without colon surgery. It was a 5 cm (2 inch) flat sessile villous adenoma colon polyp located in my cecum. All my other medical doctors told me I needed laparoscopic right hemicolectomy colon surgery to remove this polyp. They said there was no other way. But I had it removed endoscopically by EMR without colon surgery. Now the polyp is gone and I still have my colon.

I feel compelled to share this information about EMR because it was difficult to find out about EMR and to get it performed on me. My doctors knew about EMR and they knew I really wanted to save my colon, but they did not tell me about EMR. This attitude is far too common. Perhaps this information about EMR will help someone else with a large flat colon polyp who would like to remove it without removing part of the colon. EMR is a reasonable treatment option for large flat polyps that your gastroenterologist may fail to tell you about.

Endoscopic mucosal resection (EMR) is performed mainly by specially trained and equipped gastroenterologists who practice interventional endoscopy or therapeutic endoscopy instead of mainstream diagnostic endoscopy. EMR requires special skills and state of the art endoscopic equipment. It also requires more follow-up care that requires a higher level of skills and equipment. EMR is beyond the capability of most mainstream gastroenterologists so it is easier for the mainstream gastroenterologist to get rid of your polyp by simply sending you for surgery to cut out that part of your colon. But who wants to have a large section of their colon cut out if they don’t really need to?

The Mayo Clinic, one of the top medical institutions in the USA, states on their web site "endoscopic mucosal resection (EMR) is the treatment of choice for large, flat and sessile colorectal lesions" (see Endoscopic management of large, flat colorectal polyps). But this is not the case everywhere. Many (or most) other health organizations are slow to adopt these modern methods and still perform unnecessary colon surgery instead of using EMR just like they have been doing for quite a few decades.

This document describes how I found out about endoscopic mucosal resection (EMR), what it is, where to do it, my experience of removing my polyp by EMR, and why it is so important which gastroenterologist and health care organization you go to for colonoscopies, polyp removal, and follow-up care.

They Found a Colon Polyp and Recommended Colon Surgery

I had a colonoscopy in July 2007 and they found a very large 5 cm flat sessile villous adenoma colon polyp in my cecum (at the start of the colon near the junction with the small intestine). They could not remove it during the colonoscopy because it was so large and was flat like a carpet against the colon wall and draped over a haustral fold. A colon polyp this large and complicated is sometimes called a giant polyp or a difficult polyp. Fortunately the biopsy samples were benign tubulovillous adenoma.

The polyp is the light colored bumpy looking expanse in the bottom half of the photo shown above. It’s about 2 inches in diameter and a quarter inch thick.

My gastroenterologist told me very briefly as I was coming back to consciousness from the colonoscopy that they found a polyp which needed to be removed. She said fortunately all I needed was laparoscopic surgery instead of full surgery. She said I had an appointment to meet with the surgeon in a couple of days. She made it seem like it was just a small routine procedure to remove the polyp.  I thought they would just go in and remove a small little part from my colon where the polyp was located. A couple of days later I met with the surgeon. He did not have any photos of my polyp or anything yet. I thought how could he know what I need done to my colon without even looking at the colonoscopy photos. He talked about cutting out an 18-inch section of my colon. He sketched with a pen on a paper with a picture of the colon showing where he was going to remove the large section of colon as well as the ileocecal valve and large sections of associated blood vessels and lymph system. He explained that even though my biopsy samples were benign there was a significant likelihood that my polyp contained cancer anyway (Note: After my polyp was removed by EMR there was no sign of cancer). It seemed important to remove all the parts that he was showing me. And since cancer was probably in there, the sooner it was removed the better. He made it seem like it was a fairly urgent situation. He talked about how the recovery would not be all that bad. After awhile my bowel habits would probably be fairly normal again. I questioned the need for such extensive surgery just to remove a polyp. He said the decision about the surgery was not his but was the gastroenterologist's decision. He said he could do the surgery the next week. Normally it takes awhile to get an appointment for medical treatment but apparently not for colon surgery. Fortunately I was having trouble making arrangements for someone to transport me and help me after the surgery so I had to delay surgery. That gave me time to think about it.

I consulted with five gastroenterologists and two surgeons about this polyp and they all told me there is no way to heal it and there is no way to remove it except by a right hemicolectomy. That means they would remove the right side of my colon. Actually they would remove about one third (18 inches) of my colon along with the ileocecal valve between the small and large intestine and all the associated blood vessels and lymph nodes. They staple the ends of the small intestine and remaining colon together. It’s major surgery.

The colon is a big part of the body. It's about five feet long and 2.5 inches in diameter. To put this in perspective, a right hemicolectomy removes an amount of the body that is almost as much as your arm. You can get along without it, but not as well as before. The colon is there for a reason. Also, cutting out large sections of associated blood vessels and lymph system is not without consequences. When they do colon surgery, they cut away the web of connective tissue that connects the colon to the abdominal wall and other organs. Then they pull the colon out of your body through a small hole that they cut in your belly. They cut off the 18 inches of colon, staple it back together, stuff what is left of it back into the hole, and expect it to arrange and reconnect itself inside the abdomen. Why is it necessary to cut out so much of the colon just to remove a polyp? If there were a tumor in your brain or most other parts of the body they certainly would not cut out so much of your body.

If you want to see a video of a laparoscopic right hemicolectomy colon surgery from St. Mary's Medical Center in Duluth, MN, see the following Google video: Minimally Invasive Colon Surgery. (Caution, it's very graphic.)

One of the reasons they cut out so much colon when removing a polyp is that they don't know for sure if the polyp is cancerous or not just from taking a few biopsy samples. What if there is cancer in the part they don't sample? Cancer has a tendency to travel up the blood vessels and lymph system form a cancerous polyp. Surgery is expensive and traumatic, so when they do it, they want to make sure they take out all the necessary parts that might possibly contain cancer so they don’t have to do any more surgery later. So they usually take out an entire block or section of colon, which is served by a system of associated blood vessels and lymph nodes. They don't know the full status of the polyp before surgery because they haven't taken it out of the body yet and can't fully analyze it to see if it really does contain cancer or not.

But what if there were a way to remove the polyp before doing any surgery. Then the polyp could be fully analyzed in pathology and colon surgery would only be necessary in a few cases where they actually do find cancer. So in essence, they could avoid a lot of unnecessary colon surgeries. There is such a method for removing a polyp without doing surgery first. That's what this document is all about.

My doctors tried to convince me that colon surgery is no big deal. But it really disturbed me. I know many people feel comfortable with this sort of surgery and would just go ahead and get it done and over with. Or maybe they just don’t think about what they are about to do to the body and simply trust that the doctors know what is best for them. But I could not do that.

Finding an Alternative to Colon Surgery

Instead of having colon surgery, I embarked on a major quest to resolve it in a way that did not cut out part of my colon. The first step was to delay colon surgery so I could fully consider all my options including ones I didn't know about yet and ones that my doctors decided not to tell me about. I soon realized my condition was not a medical emergency. Polyps are normally very slow growing. They can take many years to get as big as mine and my polyp was benign anyway. So why be in a hurry to cut out 18 inches of colon. Once I had the surgery there would be no putting the colon back together again. I rescheduled the surgery several times until finally abandoning the idea of surgery to concentrate on a better solution. I could still get surgery at a later date if necessary.

My doctors had me convinced that my polyp could not be physically removed except by colon surgery so I concentrated on shrinking it or healing it. It’s an interesting story how I tried to shrink it, but I don’t want to distract you from endoscopic mucosal resection, so I won’t go into detail here. But I changed my life style, changed my diet, and went to many alternative health practitioners. I got two more colonoscopies to monitor my progress. My polyp did not increase in size and did not turn cancerous while I was trying to shrink it. The main benefit of my efforts was to have enough time to find out about EMR before resorting to colon surgery.

From the beginning I searched on the Internet for information about polyps. Eventually I discovered endoscopic mucosal resection (EMR) and the removal of large colon polyps. Back in 2007 information about EMR was not as available as it is now. I found the following excellent document by Dr. Brian Saunders: “How I Do It” Removing Large or Sessile Colonic Polyps (PDF). This was the turning point in my quest to remove my polyp.

What is Endoscopic Mucosal Resection (EMR)?

EMR is a method for removing a large colon polyp with special endoscopic tools and techniques without abdominal incisions or removing a section of the colon. All the work is done inside the colon with endoscopic tools similar to those used in a colonoscopy along with some special attachments and tools that they pass up the colonoscope tube. A saline solution (salt water) is injected into the submucosal layer under the polyp and then the polyp is removed with wires or cutters, either as one piece or in several pieces (piecemeal). The colon wall is protected from damage since the polyp is elevated by the saline solution.

The EMR process is shown briefly in the following photos (left to right).

  1. The polyp just before EMR.
  2. The polyp being raised by injecting salt water with blue dye into the submucosal layer under the polyp.
  3. The polyp being cut with a wire snare which is coming out of the end of the colonoscope tube. The blue color is the salt water injected submucosal layer which is protecting the colon wall from damage during this procedure.
  4. After the EMR polyp removal. There is still some colored dye showing. The polyp was completely removed down to the colon muscle wall.
  5. Three months later the colon is completely healed.

EMR colon polyp removal photo sequence

It's pretty amazing they can do this. it's all happening five feet up my colon through a colonoscope tube with sophisticated remote digital imaging, remote tools, sophisticated computer technology, and highly skilled operators.

Endoscopic Mucosal Resection (EMR) Videos

This section illustrates the EMR procedure with QuickTime videos.

Initial View

This is the initial view of the lesion, which measures about 5 cm (2 inches) in the longest diameter. The surface pattern of the tumor looks uniform and there is no erosion or ulceration. Endoscopically the tumor is most likely to be adenomatous (i.e. not cancer).

 

Injection

Saline (salt water) is injected into the tissue under the tumor to expanded it and raise the tumor from the colon wall. The salt water contains indigo carmine so the solution is tinted with a slight blue color. Thus, we know that as long as there is blue area seen, we are in the correct plane and we don't need to worry about perforation. The wall of the colon is normally only 4 mm thick but is now much thicker with the cushion of salt water. Thus, there is a lot more margin of safety. Plus, the salt water absorbs the heat from the cautery so the cauterization burn does not damage the muscle layers (see the cauterizing step below).

 

First Cut

This is the first cut using a snare. The first piece of the tumor is removed at its edge.

 

More Cuts

Numerous additional tumor cuts are performed until the tumor is gone. The blue plane is the submucosa.

 

Cauterizing Small Blood Vessels

Small blood vessels are cauterized to minimize the chance of bleeding after going home.

 

Polyp Removed

This is the resected area. The tumor is completely removed.

 

Three Month Follow-up Colonoscopy

I went back three months after the EMR procedure for a follow-up colonoscopy. The resected site is completely healed.

 

Endoscopic Mucosal Resection (EMR) Information on the Internet

There is a lot of information about EMR on the Internet but it can take time to search for it. Here are a few EMR documents that I found useful.

Where to go for EMR — California Pacific Medical Center

Finding a doctor for EMR may require some effort. If your gastroenterologist does not refer you for EMR or even inform you about it as a treatment option, then it's up to you to find a doctor on your own. I knew about EMR but had no idea how or where to have it done or whether anyone could or would remove my particular polyp. I live in Santa Cruz, California, so I searched on the web for someone who could do EMR in Northern California.

I found California Pacific Medical Center Interventional Endoscopy Services (CPMC IES) in San Francisco. CPMC IES is a large state of the art medical services center. They do a wide variety of leading edge interventional endoscopy procedures including EMR. They have a lot of experience with difficult polyps. They have advanced state of the art facilities that go beyond what is normally available to mainstream gastroenterologists so they are more able to see and work with fine details in the colon. Here are some links about it:

I have been to CPMC three times over the past two years so I am getting familiar with it. I went to CPMC for my EMR and for two follow-up colonoscopies. I am fortunate to live close enough to go there. I live in Santa Cruz, which is far enough away that it makes life a lot more pleasant to stay at a Hotel in San Francisco for a procedure at CPMC. On my last visit I stayed a couple of nights at the Hotel Kabuki in Japan Town just a few blocks from California Pacific Medical Center. It's also right next to Fillmore Street with many great little shops and restaurants. Except for having to drink the bowel prep it was sort of like taking a little vacation in San Francisco and having a colonoscopy at California Pacific Medical Center while visiting there. The Hotel Kabuki is the standard place for people to stay when they go to CPMC. They have special rates and even a shuttle that goes between the Kabuki and CPMC. It's all quite convenient. So even if you live far away from San Francisco, you can go to CPMC for EMR if you have trouble finding a place to get EMR.

List of Endoscopic Mucosal Resection (EMR) Doctors

I list below some EMR doctors that I know about. There are probably many more EMR doctors that are not on this list. People occasionally send me email and tell me about another EMR doctor so this list may gradually expand. Consider this list as a starting point to get you started in your search for a doctor. I have personal experience with Dr. Kenneth Binmoeller, Dr. Roy Soetikno, and Dr. Tonya Kaltenbach. These are the doctors I have been going to for EMR and follow-up colonoscopies since April 2009 to keep my colon healthy and whole. They are really great doctors. The other doctors in this section have a good reputation or I heard about them from people who went to them for EMR.

Kenneth Binmoeller, M.D. — California Pacific Medical Center, San Francisco, CA
Dr. Kenneth Binmoeller is the Interventional Endoscopy Services Medical Director at California Pacific Medical Center. This is where they removed my polyp by EMR. There are other doctors there too. Here is the contact information. I have written about CPMC throughout this document. In addition to EMR, this is where I go for colonoscopies these days.

Roy Soetikno, M.D. — Palo Alto, CA
Dr. Roy Soetikno works at the Palo Alto VA Medical Center and Stanford Medical School in Palo Alto, CA. He is the doctor who removed my polyp by EMR at California Pacific Medical Center. Apple Computer has a professional profile web page describing his advanced use of Macintosh computers and software for high-definition endoscopy. Dr. Soetikno has been in the news raising awareness of the cancer risk of nonpolypoid flat polyps. Here are a few links about that: Flat Polyps Raise Cancer Alarm (Video - CBS News), Flat Colon Growths More Likely to Harbor Cancer (MSNBC), Easily Overlooked Lesions Tied to Colon Cancer (New York Times).

Tonya Kaltenbach, M.D. — Palo Alto, CA
Dr. Tonya Kaltenbach (link2) works at the VA Hospital in Palo Alto. Dr. Kaltenbach is in this CBS News Video: Flat Polyps Raise Cancer Alarm.

Mayo Clinic — Jacksonville, FL
Numerous people have reported excellent results going to the Jacksonville Mayo Clinic for EMR. There are several doctors there that do EMR and they have done a few thousand EMR procedures. Here is a Mayo Clinic web page about EMR: Endoscopic management of large, flat colorectal polyps. The Mayo Clinic considers endoscopic mucosal resection (EMR) as the treatment of choice for large, flat and sessile colorectal lesions. Some of the EMR doctors at the Jacksonville Mayo Clinic are Timothy A. Woodward, Michael B. Wallace, and Massimo Raimondo.

Gottumukkala S. Raju, M.D. — Houston, TX
Dr. Gottumukkala S. Raju is at the MD Anderson Cancer Center in Houston Texas. You can read more about Dr. Gottumukkala S. Raju on these web pages: Flat Colon Polyps and Endoscopic Mucosal Resection, LinkedIn, personal web page.

Jerome Waye, M.D. — New York City
Dr. Jerome Waye (link2) is located at 650 Park Ave, New York, NY. Phone: (212) 439-7779.

Brian Saunders, M.D. — UK
Dr. Brian Saunders is the author of the first paper that I read about EMR “How I Do It” Removing Large or Sessile Colonic Polyps (PDF).

Gregory G. Ginsberg, M.D. — Philadelphia, PA
Dr. Ginsberg is located at: 3rd floor Ravdin Building 3400 Spruce Street, Philadelphia, PA 19104, Phone 215-349-8222, Fax 215-349-5915.

Douglas K. Rex, M.D. — Indiana University Hospital
Dr. Rex says on his web site "Endoscopic photographs of polyps can be submitted to Dr. Rex for consideration of the feasibility of resection by colonoscopy (contact Kelly at 317-278-9763 to send photos or arrange e-mailing)." His web site shows photos of removing large colon polyps by EMR.

Shou Jiang Tang, M.D. — Jackson, Mississippi
Dr. Shou Jiang Tan, Director of Advanced Endoscopy and Endoscopic Research, Associate Professor in Medicine, University of Mississippi Medical Center, Jackson, MS.

Norman Marcon, M.D. — Toronto, Canada
Dr. Marcon works at St. Michael's Hospital in Tornonto and is a specialist in therapeutic endoscopy, which includes EMR. Here is a link (look near the bottom of the page). Phone: 416-864-6060 x 5345

Michael D. Saunders, M.D. — Seattle
Michael D. Saunders, Digestive Disease Center, University of Washington Medical Center (UWMC), Seattle, WA

Eric M Goldberg, M.D. — Baltimore
Dr. Eric Goldberg (link2) at the University of Maryland Medical Center in Baltimore, Maryland

Neeraj Kaushik, M.D. — Manhasset, NY
Dr. Neeraj Kaushik (link2) (link3), North Shore Hospital, Manhasset, NY

Ram Chuttani, M.D. — Boston
Dr. Ram Chuttani, Director, Interventional Gastroenterology and Endoscopy at Beth Israel Deaconess Medical Center

John R. Saltzman, M.D. — Boston
John R. Saltzman (link2) (link3) Director of Endoscopy, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115

Robert Goldberg, M.D. — Miami Beach, FL
Dr. Robert Goldberg, Mount Sinai Medical Center, 4300 Alton Road, Bldg Gumenick 2nd floor Suite 2522, Miami Beach, Fl. 33140   (305) 674-2240

Laith H. Jamil, M.D. — Los Angeles, CA
Dr. Laith H. Jamil, Associate Director, Interventional Endoscopy, Cedars-Sinai Medical Center, 8700 Beverly Blvd Ste 7511, Los Angeles, CA

Iqbal S. Sandhu, M.D. — Salt Lake City, UT
Dr. Iqbal S. Sandhu, gastroenterologist at the Avenues Specialty Clinic, Intermountain Health Group in Salt Lake City, Utah.

Making Arrangements for Endoscopic Mucosal Resection (EMR)

I sent California Pacific Medical Center a letter explaining my situation and my colonoscopy reports. They called me and said they could probably remove my polyp. I arranged a special consultation meeting with Dr. Roy Soetikno at California Pacific Medical Center to get more assurance that they could remove my polyp by EMR. Dr. Soetikno said he could not be completely certain from looking at my polyp photos, which were not quite detailed enough, but there was a good chance that he could remove it if there was no cancer growing into the colon wall. He was willing to do the EMR on the basis that he would remove it if possible. It seemed that he had a pretty high confidence level that he could remove it. He told me to see my gastroenterologist and get a referral for EMR.

I went to my gastroenterologist at Kaiser Permanente and asked for a referral for EMR at California Pacific Medical Center. She said she did not recommend it. But after I pleaded my case, she reluctantly agreed that if I wanted to do it I could. She knew I was a problem patient because I would not get the colon surgery she had been recommending. She knew about EMR all along but she never told me about it. EMR is cutting edge and controversial and Kaiser does not have that capability with their normal in-house staff. I am pretty sure that if I had not been so insistent about wanting to do EMR instead of colon surgery, she would not have requested a referral for EMR. I was determined to get EMR even if I had to pay for it myself. Kaiser did approve the outside referral for EMR at California Pacific Medical Center.

Everything was set. I had a date to do it. Kaiser would pay for it. I had a ride with my good friend. All was in order.

Removing the Polyp by Endoscopic Mucosal Resection — the EMR Procedure

The big day finally arrived in April 2009. I was prepped for the procedure — no solid food for a day or so, clear liquid diet, GoLYTELY bowel prep, and all the usual stuff for a colonoscopy. The bowel prep and clear liquid diet is a difficult part of EMR and colonoscopies. We got up early and drove to San Francisco.

They took me into the procedure room and got me setup for the colonoscopy. Dr. Roy Soetikno was the doctor. I had an IV in my arm for sedation. They used little or no sedation in the first part when inserting the colonoscope tube. They used light sedation during the EMR. Doctors often use much deeper sedation for EMR than I describe here. I was pretty aware most of the time and remember quite a bit. It was fascinating to watch the EMR procedure on the colonoscopy computer monitors. They had several high-resolution computer monitors in the room. People were moving around but I could see at least one of the monitors most of the time.

I was very impressed with how much skill it took to remove the polyp. It looked like a highly skilled person was playing a high-speed action video game in my colon. I could feel the colonoscope tube moving in and out. The doctor was holding the controller on the end of the colonoscope tube. It looked like a roundish black thing with several control buttons. He was pushing and pulling the colonoscope to position it in my colon. He pressed on the control buttons to control the instruments at the end of the colonoscope tube in my colon. The instruments included things like wire loops, liquid streams, cutting, scraping, fluid injection, and such. I could not feel anything inside my colon where they were removing the polyp. Apparently the colon does not have many nerves for the conscious mind to be aware of. It was sort of like watching a movie. It did not bother me that this was actually taking place in my colon and not just on the computer screen.

At the end of the procedure they gathered all the polyp pieces into a sort of wire mesh basket and pulled them out with the colonoscope tube. It was very satisfying to see the pieces of my polyp being gathered up and taken out in the little basket. I seem to remember them saying they got it all out.

Then I don’t remember anything until I woke up in a recovery room. The light was streaming in the windows. It was nice. I was feeling pretty good. I started becoming more aware of where I was. I thought about my friend a couple of blocks away on Fillmore Street shopping and eating at fine restaurants. I found my iPhone and called her. She arrived at the recovery room. It was really good to see her.

I got my EMR report from Dr. Soetikno. The EMR was a success. They got it all out. He gave me a prescription for three days of antibiotics. He said to have a clear liquid diet for two days and then soft food for a couple of days. Watch for bleeding for up to three weeks. Don’t take aspirin or anything that can increase bleeding risk. Come back in three months for a follow-up colonoscopy.

After the Endoscopic Mucosal Resection (EMR) Procedure

We left the hospital and drove home for a couple of hours to Santa Cruz. I was very happy the polyp was gone.

I felt uncomfortable after the EMR procedure. My abdomen was gassy and tender and upset. They pump gas into the colon during the EMR to inflate the colon. Shoving all that endoscopic equipment in and out of my colon and removing a two-inch piece of flesh out of my colon was traumatic to my body even if I didn't consciously feel much.

I was really feeling the adverse effects of eating a liquid diet for a couple days and going most of the day of the procedure with no food or even anything to drink. So on top of the procedure itself, the lack of proper food and water was really affecting me.

For the next few days after the procedure I felt disoriented, uncomfortable, tired, and emotionally delicate. My system was upset due to all the strange diet and trauma from the procedure. I was worried that I might get internal bleeding. There was no way to tell since I was not going to the bathroom yet since I was not eating any solid food and I had been completely cleaned out by the bowel prep before the procedure. I was still on a clear liquid diet for two days after the EMR and I don’t feel very good on such a diet. After two days I ate a more normal diet and started feeling better. My digestive system appeared to be working normally. I was relieved that I did not appear to have any bleeding from the EMR procedure.

They took biopsy samples during the EMR procedure and I was waiting for the results. Eventually after several days I got the pathology report. The polyp pieces were villous adenoma (tubulovillous adenoma or villotubular adenoma). That means it was just a polyp and there was no cancer. If there were any cancer it would say something like carcinoma or villous carcinoma. The size of the pieces was 2” square and 0.7 cm thick (about 1/4 inch thick). This was good news. If they had found cancer in the polyp, I might need to get colon surgery, although maybe not if it was confined to the polyp and had not gone into the colon wall.

Three Month Follow-up Colonoscopy

I went back to California Pacific Medical Center for the three-month follow-up colonoscopy. Dr. Roy Soetikno was the doctor. The purpose of the follow-up was to make sure the colon healed properly and to remove any remaining or recurrent polyp tissue. The colonoscopy was very straightforward. They used minimal sedation so I was aware of what was going on the entire time. They very carefully examined the site of the polyp with magnification under the following conditions:

The purpose was to compare the pattern of the polyp resection scar area with the surrounding area looking for any irregularities. In my case the pattern was very much the same under all these viewing conditions in both the resection and surrounding areas. This indicates that there was no precancerous lesion. They biopsied the polyp site and confirmed that there was no residual adenoma tissue. The polyp healing process is complete except for more follow-up colonoscopies to check for any problems.

Following are a video and photos of my polyp resection three months after the EMR procedure.

Follow-up Colonoscopy Video

Here is a QuickTime video from the three month follow-up colonoscopy.

 

Follow-up Colonoscopy Photos

Here are three photos of the polyp resection area, one in each of the viewing conditions mentioned above.

Post EMR polyp site white light

Post EMR polyp site narrow band imaging green light

Post EMR polyp site white light blue dye

What’s Next? — More Follow-up Colonoscopies

Now that the polyp is gone, what's next? The main issue is that there might be a tiny area of polyp that was not completely removed (residual or remnant) or it might start to grow back (recurrence). It's necessary to get periodic colonoscopies to examine the resected polyp scar area to check for residual/recurrent polyp tissue and remove it while it is small. This is done more frequently at first with longer intervals after the polyp appears to be completely gone. The frequency of colonoscopies depends on various factors and is determined by the gastroenterologist who does each colonoscopy. This may seem like a lot of colonoscopies, but it is normal for anyone who gets a polyp removed by any method to have more frequent colonoscopies.

Follow-ups Nine Months After the EMR

It might seem like getting follow-up colonoscopies is straightforward. But there are pitfalls. It's important to get these colonoscopies from gastroenterologists who understand about EMR and are capable of looking for and removing residual/recurrent polyp tissue. Otherwise you could encounter a situation where the gastroenterologist finds a little bit of adenoma tissue and rather than just remove it recommends colon surgery. This would defeat the whole purpose of getting EMR. If this happens you can get another colonoscopy from a properly qualified EMR savvy gastroenterologist to remove it.

This is exactly what happened to me when I went back to Kaiser Permanente for my nine-month follow-up colonoscopy. The Kaiser gastroenterologist found a very tiny bit of adenoma tissue in the EMR scar area and instead of removing it she told me to get a cecectomy (colon surgery to remove my cecum). She showed no intention of supporting me in appropriate post-EMR care. This was quite shocking at the time but in hindsight it is not so surprising since she never wanted me to get EMR in the first place.

For the second time with Kaiser I had to take matters into my own hands to avoid unnecessary colon surgery. Without Kaiser's help I went to Dr. Roy Soetikno and Dr. Tonya Kaltenbach for a repeat colonoscopy. They examined my colon very carefully using advanced endoscopic equipment and techniques and they found and removed a very tiny 2 mm area of residual tissue and said my EMR scar area looks healthy and normal.

Follow-up Two Years After the EMR

I changed my health insurance so now it is easier to go to the gastroenterologist of my choosing. I went to California Pacific Medical Center for my two-year follow-up colonoscopy. Dr. Kenneth Binmoeller inspected the EMR scar very carefully and found and removed a very tiny 2 mm area of residual tissue. To put this in perspective, 2 mm is about the size of a pinhead. The original polyp was many hundreds of times larger (by area or volume). So 2 mm is quite small. Otherwise the site looks really good. I need to go back a year later for another look. So the polyp removal is doing well two years after removing my polyp by EMR.

Additional Thoughts about EMR and Colonoscopies

Most gastroenterologists don't do EMR or maybe more accurately they are not able to do EMR or provide adequate follow-up care after EMR since it requires specialized equipment and skills. It's important to avoid these doctors after EMR. Only go to the best EMR capable gastroenterologists that you can for EMR follow-ups since there can be vast differences in the quality of colonoscopies and what gastroenterologists do if they find a problem. In other words, for EMR follow-ups only go to interventional endoscopists instead of mainstream diagnostic endoscopists. If this is not a practical option at least try to go to a gastroenterologist who is favorable towards EMR and willing to refer you to an EMR expert if necessary.

The story of my polyp so far has been full of obstacles. I learned the hard way the difference between interventional endoscopy and mainstream diagnostic endoscopy. This is primarily because I had Kaiser Permanente health insurance. To be fair to Kaiser, many other health care organizations are very similar in how they handle a person with a large flat polyp. Kaiser is one of the largest health care providers in California. But they don't have any capability for doing endoscopic mucosal resection (EMR) for colon polyps. So when they do a colonoscopy at Kaiser they automatically assume that if they find a large flat polyp like I had, they will remove it by colon surgery. Even though EMR is possible, they won't use it and they won't tell you about it either. Furthermore, if you do manage to get a referral for EMR, they may not provide appropriate post-EMR care and may again try to send you to surgery.

When I think back to when they first discovered my polyp at Kaiser, I realize how much trouble I could have saved if I had gone to an EMR capable gastroenterologist in the first place for my first colonoscopy. They could have just removed it right then and there in my first colonoscopy and saved me a considerable amount of worry and trouble. Knowing what I know now, it seems best for people to only go to EMR capable doctors and strictly avoid the gastroenterologists that can't or won't do EMR. One never knows when they will find a polyp that would normally require colon surgery for removal but that could be removed by EMR instead of surgery. Sometimes I wonder how many people have had a large section of colon unnecessarily removed because of a polyp that could have been removed by EMR. I think the number is pretty high.

When going to a mainstream gastroenterologist for a colonoscopy it is common practice in the USA (but not in some other countries) when a big flat polyp is found to tattoo it to make it easy to find later for surgery and also to take biopsy samples. The problem is that taking biopsy samples can make it more difficult or even impossible to remove the polyp later by EMR. It can cause scar tissue that prevents the polyp from lifting when they inject saline solution under it. It does not cause problems every time but it can cause problems. It would be very disappointing to be unable to use EMR just because a biopsy was taken. In Japan where EMR is used much more widely they realize this and don’t biopsy large flat polyps that can be removed later by EMR. It is not necessary to biopsy first if EMR is going to be used later. The polyp can be thoroughly analyzed in the pathology lab after it is removed by EMR.

Problems can also occur if a gastroenterologist attempts to remove a polyp by EMR or some other method using inadequate tools or techniques and can't remove it. A failed attempt to remove a polyp can cause scar tissue and fusion of the wall layers, which can prevent or complicate performing EMR later. In this case it is probably best not to wait too long before making a second EMR attempt. It could require really specialized skills to perform EMR in this case. It might be a good idea to ask around in the EMR medical community to see if anyone can handle this more complicated case. This situation points out the wisdom of going to an experienced EMR doctor in the first place.

It really does matter which doctor you go to for advice, colonoscopies, and polyp removal.

Background

Jim SeaseI am a technical writer with an electrical engineering background who usually writes about electrical engineering topics for high tech companies in Silicon Valley (San Francisco Bay Area, California). I currently live in Santa Cruz, California.

I have a lifelong interest in health, especially alternative health. I have studied enough about the colon to realize that it’s an important part of the body that does much more than simply suck up excess water. It's a good idea to keep the colon in one piece if at all possible.

This web page was originally posted in May 2009 shortly after my EMR procedure. I revise it occasionally to reflect my latest thoughts about EMR. I get quite a bit of email from people who read this web page telling me about their experiences with polyps. My own experiences as well as those of my readers shape this web page.

I made this web page primarily to increase awareness of EMR. I am not qualified to offer medical advice so don’t expect me to tell you what to do about your polyp. Now that you know about EMR and wonder if it applies to you, the next step is probably to contact an EMR doctor. But be aware that if you ask a mainstream gastroenterologist or a surgeon about EMR you are likely to get discouraging answers. You need to communicate directly with EMR experts if you want to know what they can do for you.

 

By Jim Sease
jim@sease.com
http://www.sease.com/polyp/emr.html
http://www.sease.com