Advances, problems, and complications of polypectomy

Figures & data

Table 1 Introduction section, key points

• Screening colonoscopy with polypectomy has significantly reduced the incidence of, and mortality from, colorectal cancer.

• Polyp and adenoma detection rates are the most important markers of quality in diagnostic colonoscopy.

• Incomplete polyp resection is one of the major causes of interval cancer.

• The advanced-neoplasia potential of colonic polyps is size-dependent.

• Serrated polyps need to be carefully sought after, since they are frequently misdiagnosed and incompletely removed, and hence significantly contribute to the development of interval CRC.

• New platforms in both diagnostic and therapeutic colonoscopy are being developed.

Table 2 Diminutive and small polyps section, key points

• The vast majority of colonic polyps are diminutive (≤5 mm) or small (6–9 mm).

• Polypectomy by cold forceps biopsy is associated with high rates of incomplete removal in this setting. Polypectomy by hot forceps must be avoided, as it is associated with high complication rates.

• Cold snare polypectomy is superior to biopsy forceps in terms of complete polyp removal. It has similar complete removal rates as hot snare polypectomy, but with less complications.

• The “resect and discard” and “leave-in” policies for diminutive polyps are slowly entering clinical practice.

Table 3 Large colonic polyps or lesions section, key points

• Meticulous evaluation of the morphology (Paris classification), pitt-pattern (Kudo classification) and vascular pattern (NICE classification) dictates indications and type of treatment choice for large (≥10 mm) colorectal lesions.

• Endoscopic mucosal resection is effective in removing en-bloc lesions of 10–20 mm, and piecemeal lesions >20 mm, avoiding surgery in over 90% of patients. Piecemeal resection is associated with high adenoma recurrence rates (25% of cases), easily treated with other endoscopic mucosal resection sessions.

• Endoscopic submucosal resection is technically demanding, but has high en-bloc removal and low recurrence, rates (≥90% and ≤2% respectively).

• Endoscopic mucosal resection and endoscopic submucosal resection have an overall similar colon-preserving efficacy.

Table 4 Complications section, key points

• Diagnostic colonoscopy is extremely safe. Complications arise mostly from polypectomy with electrocautery.

• Bleeding is the most frequent complication of polyp removal (0.3–2% for diminutive and small polyps; 1–10% for endoscopic mucosal resection/endoscopic submucosal resection). In most cases, it is managed endoscopically. Risk factors include increased size and right colon location. Antiplatelet, or even anticoagulation agents do not seem to be risk factors for bleeding in small and diminutive polyps, whilst they are considered such for large polyps.

• Perforation is the second most common complication (0% for small and diminutive polyps if electrocautery is avoided; 0–1.5% for endoscopic mucosal resection and 1.5–10% for endoscopic submucosal resection in large polyps). Most cases can be managed endoscopically. Risk factors include lack of experience, larger size and right colon location.

• Post-polypectomy coagulation syndrome is rare (1–4% of cases; but only 0.07% require hospitalization). It is easily managed conservatively.