Diminutive Polyps: The Optimal Treatment Siwan Thomas-Gibson St Marks Hospital London UK
Outline How common What s the point? Polypectomy methods Structured technique
What is a Diminutive Polyp? A polyp </= 5mm Mean per colonoscopist Range Caecal intubation rate 95.2% 76.2-100 % Adenoma detection rate Mean withdrawal time 9.4 minutes 46.5% 21.9-59.8 % 5.6-12.3 minutes Polyp retrieval rate 92.7% 68.9-100 % Mean Adenomas per Patient 0.91 0.31-3.1 BCSP data England curtesy Matt Rutter
HGD What s The Risk? Malignancy 6-9mm 0.4% 0% * 10-19 7.9% 0.9% 20-29 6.1% >30mm 38.1% Pickhardt; Clinical Gastroenterology and Hepatology; 2010 5 mm? Under-estimate? 8.7% unfavourable histology in diminutive polyps Repici et al Endoscopy 2012
Polypectomy Technique for Diminutive Lesions
Diminutive Polyps Morphology Polyp position Polyp site On insertion or withdrawal Hot Biopsy?? Cold forceps Cold snare Hot snare Lift or not Tip: Position the polyp
Hot Biopsy Consider using cold forceps Technique all important: BIOPSY not polypectomy Polyps <4mm Not proximal to splenic flexure Many say never 22% residual polyp left (Ellis GIE 1997) Risk of bleed and perforation If 2-3mm can remove with cold forceps= polypectomy Tip: Think cold forceps
Easy Cold Forceps >3mm consider jumbo forceps Safe: negligible risk of bleeding/perforation Retrieval and histological confirmation BUT Minor bleeding may make assessment of completeness difficult? 61% incomplete removal, 30% recurrence Fyock WJG 2010, Singh GIE 2004 Rex Endoscopy 2010, Tolliver GCNA 2008 Repici Endoscopy 2012, Graser Gut 2009, Hewett CGH 2011
Cold Snare: no lift
Tip: Use mini-snare
Definitive resection?
Cold Snare Indicated (unfavourable histology up to 8.7%) Easy, usually Safe (2.2% immediate, controlled, bleeding) Doing nothing leaves risk 100% time! BUT Retrieval can be difficult (84-95% retrieval rates) Can be incomplete Repici Endoscopy 2012 Monkemuller CGH 2009 Deenadayalu GIE 2005
Hot Snare, no lift Tip: Using heat- tent the mucosa
Lift or no lift? Morphology Size polyp Site polyp Sessile polyps Most sessile lesions are semi-pedunculated, pseudo-stalk Snare in one piece Right colon, think lift True flat/depressed lesions: lift Tip: If sessile think lift?
Cold Snare: Lift
Hot Snare Lift Tip: Always close the snare yourself
Small Stalked Polyps Position polyp favourably Check and mark snare Check diathermy settings Coag +/- Cut Position foot pedal Open Snare within scope channel, beyond polyp
Push snare sheath against stalk Close snare from behind Thinnest part of stalk (mid-upper 1/3) Close snare to the mark (begin coaptation) Endoscopist takes snare Apply current, watch for visible whitening Endoscopist squeezes and transects Watch where polyp falls (or liquid pooling)
Top Tips: Small Polyps Tip: Position the polyp Tip: Think cold forceps Tip: Use mini-snare Tip: If sessile think lift? Tip: Always check The Mark Tip: Using heat- tent the mucosa Tip: Close the snare yourself Tip: Retrieve on snare / look for fluid pool
DOPyS Assessment/ pre-polypectomy Stalked polyps Sessile polyps/emr Have a routine Stick to it Trainee certification Bowel cancer screener accreditation Post-polypectomy Overall competency