Is a location-based resect-and-discard strategy the right approach?

We read with interest the study by Taghiakhbari et al. that concluded a location-based resect-and-discard (LBRD) strategy, in which “all rectosigmoid diminutive polyps were considered hyperplastic and all polyps located proximal to the sigmoid colon were considered neoplastic,” achieved high surveillance interval agreement with pathology-based surveillance intervals and outperformed optical diagnosis [1].

Although strong advocates of a “resect-and-discard” policy, we suggest caution with an LBRD approach. Location-based assumptions about diminutive polyps without careful optical diagnosis and photodocumentation inevitably lead to individual polyp diagnostic errors and a reduction in our knowledge and understanding of colonic neoplasia. An LBRD approach would deskill the colonoscopist in optical diagnosis and, in our opinion, be a reverse step in achieving high quality colonoscopy, particularly when histopathology already provides a “high bar” to overcome for a resect-and-discard strategy to be acceptable. Already, AI systems are being developed to guide the endoscopist with optical diagnosis calls, making a resect-and-discard strategy even more compelling, but this inevitable development also emphasizes the need for endoscopists to be skilled in optical diagnosis when the AI is wrong, fails, or is unavailable. More importantly, an LBRD approach might lead to significant errors for individual patients and attract litigation. For example, diminutive advanced adenomas, although extremely rare in Western practice, can be seen in the rectosigmoid and sometimes amongst multiple hyperplastic polyps [2]. Without careful scrutiny and an understanding of optical diagnosis appearances, these lesions could be overlooked and left in situ.

The authors concluded an LBRD strategy was superior to an optical diagnosis strategy. However, an alternative interpretation would be that there was insufficient experience or training of the colonoscopists in optical diagnosis. ESGE guidelines and our clinical experience suggest at least 120 optical diagnoses are required in clinical practice before acceptable accuracy is achieved and this was not a stated requirement in this study.

Publication History

Article published online:
29 March 2022

• References

• 1 Taghiakbari M, Pohl H, Djinbachian R. et al. The location-based resect and discard strategy for diminutive colorectal polyps: a prospective clinical study. Endoscopy 2021; DOI: 10.1055/a-1546-9169.
• 2 Ponugoti PL, Cummings OW, Rex DK. Risk of cancer in small and diminutive colorectal polyps. Dig Liver Dis 2017; 49: 34-37