How we resect colorectal polyps < 20 mm in size

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 [1]. 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 [1]. 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.

• References

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