Advances in the removal of diminutive colorectal polyps

Abstract

Diminutive polyps (<5 mm in diameter) represent the majority of polyps found during colonoscopy; about a half of them are adenomatous, with low risk of advanced neoplasia. Recent studies have demonstrated that cold polypectomy should be considered the recommended approach for resecting diminutive polyps and that cold snaring may be superior to cold forceps biopsy, at least for polyps of 4–5 mm. Recently, electronic chromoendoscopy has been applied to characterization of diminutive polyps to discriminate adenomatous from nonadenomatous lesions. Optical diagnosis of polyp histology could potentially exert huge cost savings by the ‘resect and discard’ strategy for diminutive polyps and ‘leaving-in’ for diminutive hyperplastic polyps in the recto-sigmoid colon. These policies represent the mainstay for adopting endoscopy-directed post-polypectomy surveillance strategies, endorsed by both American and European Endoscopy Societies. Accuracy of both histology and surveillance intervals predictions from academic centers have been encouraging, although the same performance has not been replicated in community practices.

Keywords:

• cold polypectomy
• diminutive polyps
• narrow band imaging
• post-polypectomy surveillance
• resect and discard

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Diminutive polyps represent about 60–80% of those encountered during colonoscopy and about a half of them is adenomatous. The risk of high-grade dysplasia, villous histology or invasive cancer is extremely low.

• Several techniques can be used for diminutive polyp removal. Cold techniques are associated with an excellent safety profile. For resection completeness, cold biopsy and cold snare are two alternatives to be proposed for 1–3 mm polyps, whereas cold snare should be used for bigger lesions.

• Data on real-time endoscopic prediction of adenomatous histology by narrow band imaging and subsequent endoscopy-directed post-polypectomy surveillance strategy have shown high levels of accuracy. These results have not been consistently replicated in community hospitals.

• Recent studies demonstrated that a formal structured training on endoscopic prediction of polyp histology can homogenize the performances of endoscopists from referral and community centers. This finding stresses the importance of educating non-experts to warrant high-quality performances, before translating the strategy outside academic centers.