Diminutive Polyps

Quality in Endoscopy: Colonoscopy, Berlin 2012

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 46.5% 21.9-59.8 %

Mean withdrawal time 9.4 minutes 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


What’s The Risk? HGD 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

• Hot Biopsy??

• Cold forceps

• Cold snare

• Hot snare

• Lift or not

• Morphology

• Polyp position

• Polyp site

• On insertion or

withdrawal

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


Cold Forceps

• Easy

• >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: Always check ‘The Mark’

Tip: Position the polyp

Tip: Think cold forceps

Tip: Use mini-snare

Tip: If ‘sessile’ think ‘lift’?

Tip: Close the snare yourself

Tip: Using heat- tent the mucosa

Tip: Retrieve on snare / look for fluid pool


DOPyS

• Have a routine

• Stick to it

• Trainee

certification

• Bowel cancer

screener

accreditation

Assessment/

pre-polypectomy

Sessile polyps/EMR

Post-polypectomy

Overall competency

Stalked polyps

Diminutive Polyps

Documents

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