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How we resect colorectal polyps < 20 mm in size
14 September 2018 (online)
This article is being published jointly in Gastrointestinal Endoscopy and Endoscopy.
Copyright © 2018 by the American Society for Gastrointestinal Endoscopy and Georg Thieme Verlag KG
We review our approach to resection of colorectal polyps < 20 mm in size. Careful inspection of all lesions is appropriate to assess the type of lesion (adenoma vs. serrated) and evaluate the risk of cancer, which is highly associated with lesion size. Polyp resection is in the midst of a “cold revolution,” particularly for lesions < 10 mm in size but also for some larger lesions. Cold forceps are sometimes appropriate for 1- to 2-mm lesions that can be engulfed in 1 bite, but we use cold snaring for almost the entire set of lesions < 10 mm. For 10- to 19-mm conventional adenomas, we rely primarily on hot snare resection. EMR, preferably en bloc, is appropriate for bulky nongranular conventional adenomas and nongranular adenomas with depression in this size range. For sessile serrated polyps 10 to 19 mm in size our approaches differ to some extent, with one of us using primarily “cold EMR” and the other using primarily hot EMR techniques.
Colorectal polyps and flat lesions < 20 mm in size constitute 95 % of all colorectal neoplasms and therefore comprise the overwhelming majority of resections performed by colonoscopists. For high-level detectors, about 80 % of lesions are ≤ 5 mm in size, and 90 % are < 10 mm in size . The risk of cancer in lesions ≤ 5 mm in size is negligible, is far below 1 % in lesions for 6 to 9 mm in size, and is about 1 % to 2 % in lesions 10 to 19 mm in size . Essentially, all benign colorectal lesions < 20 mm, with the exception of certain lesions extending into the appendix or terminal ileum, are endoscopically resectable, with lower risks and costs than surgical resection. Referral of benign lesions < 20 mm in size for surgical resection is a particularly problematic use of resources and puts patients at unnecessary risk. Thus, the modern colonoscopist must be proficient in the safe and effective resection of these colorectal lesions. If lesions in this size range defy resection, they should be referred to a center with expertise in endoscopic resection and not to surgery.
- 1 Rex DK, Repici A, Gross SA. et al. High-definition colonoscopy versus Endocuff versus EndoRings versus full-spectrum endoscopy for adenoma detection at colonoscopy: a multicenter randomized trial. Gastrointest Endosc 2018; 88: 335-344
- 2 Pohl H, Srivastava A, Bensen SP. et al. Incomplete polyp resection during colonoscopy-results of the complete adenoma resection (CARE) study. Gastroenterology 2013; 144: 74-80
- 3 Duloy AM, Kaltenbach TR, Keswani RN. Assessing colon polypectomy competency and its association with established quality metrics. Gastrointest Endosc 2018; 87: 635-644
- 4 Gupta S, Bassett P, Man R. et al. Validation of a novel method for assessing competency in polypectomy. Gastrointest Endosc 2012; 75: 568-575
- 5 Park SK, Ko BM, Han JP. et al. A prospective randomized comparative study of cold forceps polypectomy by using narrow-band imaging endoscopy versus cold snare polypectomy in patients with diminutive colorectal polyps. Gastrointest Endosc 2016; 83: 527-532
- 6 Peluso F, Goldner F. Follow-up of hot biopsy forceps treatment of diminutive colonic polyps. Gastrointest Endosc 1991; 37: 604-606
- 7 Bassan MS, Cirocco M, Kandel G. et al. A second chance at EMR: the avulsion technique to complete resection within areas of submucosal fibrosis. Gastrointest Endosc 2015; 81: 757
- 8 Tutticci N, Burgess NG, Pellise M. et al. Characterization and significance of protrusions in the mucosal defect after cold snare polypectomy. Gastrointest Endosc 2015; 82: 523-528
- 9 Tutticci NJ, Hewett DG. Cold EMR of large sessile serrated polyps at colonoscopy (with video). Gastrointest Endosc 2018; 87: 837-842
- 10 Tate DJ, Awadie H, Bahin FF. et al. Wide-field piecemeal cold snare polypectomy of large sessile serrated polyps without a submucosal injection is safe. Endoscopy 2018; 50: 248-252
- 11 Hewett DG, Kaltenbach T, Sano Y. et al. Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging. Gastroenterology 2012; 143: 599-607
- 12 Moss A, Bourke MJ, Williams SJ. et al. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology 2011; 140: 1909-1918