JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 00, Number 00, 2018

ª Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2017.0633

Chromoendoscopy Plus Mucosal Resection

Versus Conventional Electrocoagulation
for Intestinal Polyps in Children:
Two Case Series

Quan Zhan, BS and Chao Jiang, BS

Downloaded by Karolinska Institutet University Library from www.liebertpub.com at 08/25/18. For personal use only.

Abstract

Background: Conventional high-frequency electrocoagulation (HFEC) of intestinal polyps may be difficult in

children and endoscopic mucosal resection (EMR) could be a less invasive option. Chromoendoscopy improves
tissue localization during endoscopy, but its exact influence on the outcomes of children with intestinal lesions
is still unknown.
Aims: To analyze a series of children treated with EMR or HFEC and assess the value of chromoendoscopy.
Methods: This was a retrospective analysis of two case series of patients treated at the Gastroenterology De-
partment of the Guiyang Children’s Hospital between February 2014 and November 2016. The children underwent
EMR (n = 34) or conventional HFEC (n = 120). Demographic, clinical, and perioperative data were analyzed.
Results: The polyps were larger in the HFEC group [median, 3.9 (0.1–27.0) versus 1.3 (0.03–64.0) mm, P = .03].
There was a higher frequency of multiple polyps in the EMR group (50.0% versus 15.1%, P < .001). Operation
time and intraoperative bleeding were similar between the two groups (both P > .05). Hospital stay was longer with
EMR than with HFEC [median, 5 (3–12) versus 4 (2–14) days, P = .02]. There was no intestinal perforation in
either group. Postoperative bleeding amount was similar in both groups (P = .73). In the EMR group, 19 patients
were operated using chromoendoscopy, whereas only 2 patients in the HFEC group were operated.
Conclusion: EMR could be appropriate for the treatment of intestinal polyps in children.

Keywords: chromoendoscopy, children, intestinal polyps, endoscopic mucosal resection

Introduction snaring-electrocoagulation of polyps in children. For instance,

flat wide-based sessile polyps close to the anus are very dif-

C olonic polyps are the major cause of lower gastroin-

testinal hemorrhage in children. Most polyps in children
are in the rectum and the peak incidence is between 2 and 10
years of age (85%).1,2 Rectal bleeding is the presenting
symptom in most children (75%) and the polyps are usually
solitary (94%), juvenile (86%), and located in the rectosigmoid
area (87%).1,2 With the increasing application of colonoscopy
in children, the detection of multiple colorectal polyps, early
micropolyps, flat wide-base polyps, and polyps at special parts
is increasing in children.1–3 Malignant changes of colorectal
polyps in children have also been reported.1,4 Polyps in chil-
dren may have a familial component.5,6
Because of their malignant potential, all polyps in children
must be removed.1,4 Colonoscopic high-frequency electro-
coagulation (HFEC) is the main treatment method.1,4,7
Nevertheless, there are several disadvantages to conventional
ficult to snare. In addition, it is easy to snare too much intes-
tinal tissues during conventional snaring-electrocoagulation,
increasing the risk of perforation. It is also difficult to obtain
complete biopsies when using conventional electrocoagulation
for micropolyps. A surgical resection may have to be consid-
ered in these cases, but it is invasive.8
Intestinal polyps in adults may be resected using endo-
scopic mucosal resection (EMR), which includes submucosal
injection-assisted EMR, cap-assisted EMR (EMRC), and
endoscopic piecemeal mucosal resection (EPMR).9–11 Be-
cause of the differences in the size of the anatomic structures,
techniques for adults cannot always be used directly in chil-
dren. Chromoendoscopy is the use of staining to improve tissue
localization, characterization, and diagnosis during endoscopy,
and it is safe, inexpensive, and quick.12,13 In contrast, the in-
terpretation of the findings is not always easy. In addition, its

Department of Gastroenterology, Maternal and Child Health-Care Hospital in Guiyang, Guiyang, China.

1
 2 ZHAN AND JIANG
exact influence on the outcomes of patients with intestinal le-
sions is still unknown.14,15
Considering the need for removing colorectal polyps in
children, the present study aimed to analyze our series of
children treated with EMR between February 2014 and April
2016, and assess the value of chromoendoscopy. The results
could help shedding some light on the appropriate manage-
ment of these patients.
Materials and Methods
Study design and patients
This was a retrospective analysis of patients treated at the
Gastroenterology Department of the Guiyang Children’s
Hospital between February 2014 and November 2016. All
included children were confirmed with colonic polyps by
Downloaded by Karolinska Institutet University Library from www.liebertpub.com at 08/25/18. For personal use only.
colonoscopic examinations. The study was approved by the
Ethics Committee of the Guiyang Children’s Hospital. The
need for individual consent was waived by the committee
because of the retrospective nature of the study.
The inclusion criteria were (1) <14 years of age, (2) di-
agnosis of intestinal polyps,1–3 and (3) surgical treatments.
For most children, the families were asked to sign the in-
formed treatment consent after the endoscopic examinations,
and surgery was completed during the endoscopic examina-
tion. As these were child patients, such procedures could
benefit the children and their families by simplifying the pro-
cedures and reducing the number of bowel preparations and
pain from repeated operations. In addition, some tiny lesions
may not be easy to be found again during re-examination.
The indications for endoscopy were (1) symptoms and signs
such as hematochezia, abdominal pain, stool changes, history
of intestinal polyps, and family history; or (2) transferred from
other regional hospitals for hematochezia and other symptoms,
and suspected with colonic polyps that needed colonoscopic
examinations.
The exclusion criteria were (1) Peutz-Jeghers syndrome,
(2) malignant tumor or hematological diseases, or (3) coag-
ulation disorders.
Treatments and grouping
The polyps were classified according to the Yamada clas-
sification.16 The children with Yamada type I polyps, most
children with Yamada type II polyps, and some children with
Yamada type III polyps underwent EMR. Children with giant
wide-base polyps underwent EPMR. Children with Yamada
type II polyps close to the anus underwent EMRC. All the
other children with polyps during the same time period were
included as controls and underwent routine HFEC.
Endoscopic mucosal resection
EMR was performed using a PEF-Q180AI electronic colo-
noscope, PSD-30 high frequency generator, SD-5 U/6 U-1
electronic snare, NM-400 L-0423 syringe, HX-110UR titanium
clip releaser (if needed), HX-610-135 titanium clip (if needed),
and MH-593 transparent cap (all from Olympus, Tokyo, Ja-
pan). Normal saline was used for the submucosal injection.
For mucosal staining, the indigo carmine mucosal staining
agent (Nanjing Technology Co., Ltd., Nanjing, China; #MTN-
DYZ-15; concentration: 0.2% – 0.05%) was used for staining
the colonic mucosa through an endoscopic spraying tube (WP-
18/1800; Nanjing Technology Co., Ltd.). The patients with
polyps confirmed by colonoscopy were scheduled for HFEC or
EMR. The mucosal staining agent was routinely sprayed to the
intestinal segments with polyps, sigmoid colon, and high-risk
areas of the rectum to fully display the outline of the polyps
and the border between the base and pedicle, which could help
in determining the site for submucosal injection. In addition,
these procedures could also fully display the small polyps that
could not be clearly displayed, or easy to be missed by con-
ventional colonoscopy, and thus reduce the rate of misdiagnosis.
For submucosal injection-assisted EMR, the visual field
was fully exposed to observe the location, size, shape, and
base of the polyps. For the submucosal injection, the needle
of the syringe was inserted at 2 mm to the margin of the lesion
toward the center of the lesion, and saline was injected to the
submucosal layer to form a ‘‘saline cushion’’ to lift the lesion
sufficiently from the muscular layer. Then, 2–10 mL of nor-
mal saline was injected until the surrounding mucosa showed
the lifting sign. No multipoint injection was conducted. The
lesion was successfully snared, and the polyps were com-
pletely removed for pathological examinations.
For the children in whom the lesion was not easy to snare,
EMRC was conducted. Distal-end transparent cap matching
the colonoscope was selected and fixed to the leading end of
the colonoscope. Two methods of cap assistance could be
used. First, the snare was placed in the transparent cap. After
the colonoscope was delivered to the lesion area, the front
end of the cap was aimed at the lesion center. Then, appro-
priate negative pressure was applied to suck the lesion into
the cap, after which the snare was tightened for the snaring of
the lesion. The other method was that after approaching the
lesion with a colonoscope equipped with a transparent cap,
the space between the cap and the lesion (or use the cap to
push aside the polyps and intestinal folds to form a space) was
used to deliver the snare, and then snaring was conducted.
The first method was rarely used as the intestinal wall of
children is relatively thin and the polyps are generally small,
thus the negative pressure snaring could easily snare too
much intestinal tissues, and the operators could not be sure
whether the muscular layer was also snared or not. Since the
second method uses the space between the polyps and colo-
noscope generated by the cap, the operation could be con-
ducted under visual conditions, which not only facilitated
snaring but also ensured the safety of electrocoagulation. The
second method was used in this study to remove the polyps at
the pectinate line close to the anus.
For Yamada type II polyps >20 mm and with a relatively
wide base (about 15 mm), EPMR was applied. The first re-
section of the EPMR was started from the position relatively
hard to be resected, and the second tissue to be resected was
adjacent to the margin of the first resection to avoid residual
lesion. When the bulge of the residual lesion was not suffi-
cient, submucosal injection of 0.01% adrenalin saline could
be conducted again.
The amount of intraoperative bleeding was grossly esti-
mated by the surgeon by direct observation.
Postoperative management
The tissues resected were sent for pathological examina-
tions. The children were hospitalized. The children were asked
to avoid intense activities. Liquid diet was provided for 3 days,
 CHROMOENDOSCOPY FOR INTESTINAL POLYPS IN CHILDREN 3

Table 1. Baseline Characteristics of the Patients sented as median (range) and analyzed using the Wilcoxon
test. Categorical data were presented as frequencies and ana-
EMR Electrocoagulation P
(N = 34) (N = 120) value lyzed using the Fisher exact test. SPSS 16.0 (IBM, Armonk,
NY) was used for analysis. Two-sided P-values <.05 were
Gender .735 considered statistically significant.
Male 26 (76.5%) 95 (79.2%)
Female 8 (23.5%) 25 (20.8%)
Age (months) 60 (24–150) 48 (12–168) .399 Results
Duration of symptoms 6 (0.5–60) 6 (0.5–72) .405
(months) Characteristics of the patients
Size of the polyps 1.25 3.94 .032
(mm) (0.03–64.00) (0.13–27.00) Table 1 presents the characteristics of the patients. There
Location of the polyps — were no differences in gender, age, and duration of symptoms
Ascending colon 1 (2.9%) 0 between the two groups. The polyps were larger in the
Transverse colon 9 (26.5%) 6 (5.0%) electrocoagulation group (n = 120) [median, 3.9 (0.1–27.0)
Descending colon 8 (23.5%) 14 (11.7%) versus 1.3 (0.03–64.0) mm, P = .03] than in the EMR group
Sigmoid colon 14 (41.2%) 51 (42.5%)
Rectum 22 (64.7%) 61 (50.8%) (n = 34). There was a higher frequency of multiple polyps in
the EMR group (50.0% versus 15.1%, P < .001).
Downloaded by Karolinska Institutet University Library from www.liebertpub.com at 08/25/18. For personal use only.

Single/multiple
Single 17 (50.0%) 101 (84.9%)
Multiple 17 (50.0%) 18 (15.1%)
EMR, endoscopic mucosal resection.
and the children were ensured to keep their bowels open. In
addition, the clinicians were very careful to identify any delayed
bleeding, perforation, and abdominal distension. The stools
were examined for fecal blood during hospitalization.
Data collection
Demographic (gender and age), clinical (symptoms, polyp
size, number, and location), and perioperative (operation
time, bleeding, hospital stay, and adverse events) data were
extracted from the medical charts.
Statistical analysis
Continuous data were tested for normal distribution using
the Kolmogorov–Smirnov test. Normally distributed data were
expressed as mean – standard deviation and analyzed using
the Student t test. Non-normally distributed data were pre-
<.001
Perioperative characteristics
Operation time and intraoperative bleeding were similar
between the two groups (both P > .05). Hospital stay was
longer with EMR than with conventional electrocoagulation
[median, 5 (3–12) versus 4 (2–14) days, P = .02] (Table 2).
Adverse events
There was no intestinal perforation. Postoperative bleed-
ing was similar between the two groups (5.9% versus 1.7%,
P = .73).
Chromoendoscopy
Chromoendoscopy data were missing for some patients
(n = 4 in the EMR group and n = 75 in the electrocoagulation
group). In the EMR group, 19 patients were operated using
chromoendoscopy, whereas only 2 patients in the electro-
coagulation group were operated (Table 3). Among patients
who received EMR, operation time was a little longer for
those who received chromoendoscopy (27 versus 20 minutes,

Table 2. Perioperative Data

EMR (N = 34) Electrocoagulation (N = 120) P value
Operation time (min) 24.7 – 7.0 25.8 – 6.5 .493
Intraoperative bleeding 6 (17.7%) 15 (12.5%) .495
Hospital stay (days) 5 (3–12) 4 (2–14) .022
EMR, endoscopic mucosal resection.

Table 3. Subgroup Analysis

EMR Electrocoagulation
Chromo (N = 19) No chromo (N = 11) P value Chromo (N = 2) No chromo (N = 43) P value
Operation time (min) 27 (15–40) 20 (15–30) .021 35 (30–40) 26 (15–40) .085
Hospital stay (days) 5 (3–12) 5 (4–8) 1.000 3.5 (2–5) 4 (2–13) .607
Intraoperative blood 0 (0–2) 0 (0–1.5) .866 0 (0–0) 0 (0–15) .618
loss (mL)
Postoperative blood loss 0 0 1.000 0 2 (1.7%) .933
Chromoendoscopy data were missing for some patients (n = 4 in the EMR group and n = 75 in the electrocoagulation group).
Chromo, chromoendoscopy; EMR, endoscopic mucosal resection.
 4 ZHAN AND JIANG
P = .021). There was no difference for the other variables and
for the electrocoagulation group (all P > .05).
Discussion
This study aimed to analyze a series of children treated
with EMR or HFEC and assess the value of chromoendo-
scopy. Operation time and intraoperative bleeding were
similar between the HFEC and EMR groups. Hospital stay
was longer with EMR than with HFEC. There was no in-
testinal perforation in either group. Postoperative bleeding was
similar between the two groups. In the EMR group, 19 patients
were operated using chromoendoscopy, whereas only 2 pa-
tients were operated in the HFEC group. Chromoendoscopy
led to a longer operation in the EMR group. The results suggest
that EMR could be appropriate for the treatment of intestinal
Downloaded by Karolinska Institutet University Library from www.liebertpub.com at 08/25/18. For personal use only.
polyps in children.
Only very few studies reported treating colonic polyps in
children with colonoscopic minimally invasive methods, and it
is generally considered that the same principles apply from
adults to children. With the wider application of colonoscopy
in children, increasing number of flat small polyps are dis-
covered. In addition, some large polyps require piecemeal
resection under colonoscopy. We conducted all three types of
EMR in children with colorectal polyps and observed no se-
vere adverse events (such as perforation). EMR in children is
specifically suitable for sessile, early, tiny, or wide-base pol-
yps, as well as polyps at special sites that need transparent cap
assistance or huge polyps that need fractional resection. Such
polyps are difficult to be snared, or it is easy to snare too much
intestinal tissues. As malignant change or submucosal infil-
tration are very rare in polyps in children, and submucosal
injection easily result in a saline cushion, the percentage of the
children suitable for EMR is, theoretically, higher than adults.
For some short-pedicle polyps, normal saline could also be
injected to form a saline cushion to increase the thickness of
the intestinal wall, and thus increase the safety of EMR.
We summarize our experience of EMR in children as fol-
lows. First, appropriate bowel preparation should be per-
formed and equipment should be readily available (titanium
clip and transparent cap, if possible). To prevent intraoperative
bleeding and perforation, titanium clip should be used rou-
tinely. If the site and size of the lesion are not suitable for
conventional snaring, cap-assisted EMR should be considered.
Second, submucosal injection during the operation is the key
to prevent perforation. The site of submucosal injection should
uplift the lesion but not cover the visual field. The volume of
normal saline injected should be enough, and repeated mul-
tipoint injection could be performed if necessary to separate
the mucosal layer from the muscular layer, and form the saline
cushion. This procedure could facilitate snaring the lesion.
The separation effect of the saline cushion prevents perfora-
tion. The experience from adults suggests that if the time of
EMR is too long, repeated injection may be needed due to the
saline absorption and loss.9–11 Third, when the assistant is
conducting the submucosal injection, we should ask him/her to
inject slowly and evenly to prevent submucosal hematoma
caused by too high pressure and too fast injection. If the wound
is too large after the removal of the polyps, a titanium clip
could be used to close the wound. Fourth, during snaring, the
tissues that are not uplifted should not be snared. After the
lesion is snared, the snare is fully lifted and quickly shaken,
whereas the assistant opens and closes the snare several times,
after which the coagulation could be conducted. The aim of
this procedure is to prevent the snaring of the deep muscular
layer and injuries to deep tissues. Fifth, EPMR is safer for
sessile polyps >4 cm, as the snare and resection in one time for
relative huge lesion are easy to snare deep tissues, and long
coagulation could result in too high local temperature and lead
to perforation. Sixth, we recommend using titanium clip to
close the wound after EMR, especially for patients treated in
the out-patient department. The patients should rest for 1 week
after the operation, with the diet well controlled and bowels
kept open.
Nevertheless, EMR is not suitable for all lesions in chil-
dren. Indications for EMR in children with colonic polyps
could be (1) Yamada type I or II sessile polyps <1 cm; (2) for
wide-base polyps with base width <2 cm or some LST,
EPMR could be conducted; (3) polyps at special sites and
<2 cm are hard to be snared, and EMRC could be conducted;
and (4) for short-pedicle polyps <2 cm, using EMR could
increase the safety of electrocoagulation.
In this series, chromoendoscopy only led to a longer op-
eration in the EMR group, which was to be expected because
of the extra procedure. Chromoendoscopy had no impact on
hospital stay, intraoperative blood loss, and postoperative
blood loss. Of course, the sample size is probably too small to
reach any firm conclusion on the matter. Nevertheless, these
results suggest, for now, no added value of chromoendoscopy
in these patients. These results are supported by Ravelli
et al.,17 who showed that chromoendoscopy did not add any
diagnostic value in children with celiac disease. Additional
studies are necessary to examine this issue.
This study is not without limitations. The sample size was
small and from a single center. The retrospective nature of the
study prevented from analyzing data that were not recorded
in the charts. In China, pediatric patients are discharged only
when the patient is completely stable and there is a certainty
that no adverse event will occur. This could limit the gen-
eralizability of our results to Western patients. Finally,
bleeding was only qualitatively or semiquantitatively evalu-
ated. Additional studies are necessary to confirm the benefits
and safety of EMR in children.
In conclusion, EMR is a minimally invasive colonoscopic
treatment method that could be used to remove effectively
and completely the special types of polyps in the lower
gastrointestinal tract of children.
Acknowledgment
This work was supported by Science and Technology of
Guizhou Province [Qiankehe LH Foundation (#[2014] 7299)].
Disclosure Statement
No competing financial interests exist.
References
1. Nagasaki A, Yamanaka K, Toyohara T, Ohgami H, Aoki T,
Sueishi K. Management of colorectal polyps in children.
Acta Paediatr Jpn 1993;35:32–35.
2. Haghi Ashtiani MT, Monajemzadeh M, Motamed F, et al.
Colorectal polyps: A clinical, endoscopic and pathologic
study in Iranian children. Med Princ Pract 2009;18:53–56.
 CHROMOENDOSCOPY FOR INTESTINAL POLYPS IN CHILDREN 5

3. de Ridder L, van Lingen AV, Taminiau JA, Benninga MA.
Rectal bleeding in children: Endoscopic evaluation re-
visited. Eur J Gastroenterol Hepatol 2007;19:317–320.
4. Coburn MC, Pricolo VE, DeLuca FG, Bland KI. Malignant
potential in intestinal juvenile polyposis syndromes. Ann
Surg Oncol 1995;2:386–391.
5. Pillai RB, Tolia V. Colonic polyps in children: Frequently
multiple and recurrent. Clin Pediatr 1998;37:253–257.
6. Adolph VR, Bernabe K. Polyps in children. Clin Colon
Rectal Surg 2008;21:280–285.
7. Corredor J, Wambach J, Barnard J. Gastrointestinal polyps
in children: Advances in molecular genetics, diagnosis, and
management. J Pediatr 2001;138:621–628.
8. Wang LC, Lee HC, Yeung CY, Chan WT, Jiang CB.
Gastrointestinal polyps in children. Pediatr Neonatol 2009;
50:196–201.
9. Mannath J, Ragunath K. Endoscopic mucosal resection:
Downloaded by Karolinska Institutet University Library from www.liebertpub.com at 08/25/18. For personal use only.
13. Trivedi PJ, Braden B. Indications, stains and techniques in
chromoendoscopy. QJM 2013;106:117–131.
14. Buchner AM. The Role of Chromoendoscopy in evaluat-
ing colorectal dysplasia. Gastroenterol Hepatol 2017;13:
336–347.
15. Brown SR, Baraza W, Din S, Riley S. Chromoscopy versus
conventional endoscopy for the detection of polyps in the
colon and rectum. Cochrane Database Syst Rev 2016;4:
CD006439.
16. Yamada’s Textbook of Gastroenterology. Chichester: John
Wiley & Sons, Ltd., 2016.
17. Ravelli AM, Tobanelli P, Minelli L, Villanacci V, Cestari
R. Endoscopic features of celiac disease in children. Gas-
trointest Endosc 2001;54:736–742.
Address correspondence to:

Who and how? Ther Adv Gastroenterol 2011;4:275–282. Quan Zhan, BS

10. Conio M, Blanchi S, Repici A, Ruggeri C, Fisher DA, Fi- Department of Gastroenterology
liberti R. Cap-assisted endoscopic mucosal resection for Maternal and Child Health-Care
colorectal polyps. Dis Colon Rectum 2010;53:919–927. Hospital in Guiyang
11. Kume K, Murata I, Yoshikawa I, Yamasaki M, Kanda K, Guiyang 550003
Otsuki M. Endoscopic piecemeal mucosal resection of large China
colorectal tumors. Hepato Gastroenterol 2005;52:429–432.
12. Fennerty MB. Tissue staining. Gastrointest Endosc Clin N
Am 1994;4:297–311. E-mail: haifei1016@sina.com