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Quality in Endoscopy: Colonoscopy, Berlin 2012
Diminutive Polyps:
The Optimal
Treatment
Siwan Thomas-Gibson
St Marks Hospital
London
UK
Quality in Endoscopy: Colonoscopy, Berlin 2012
Outline
• How common
• What’s the point?
• Polypectomy methods
• Structured technique
Quality in Endoscopy: Colonoscopy, Berlin 2012
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
Quality in Endoscopy: Colonoscopy, Berlin 2012
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
Quality in Endoscopy: Colonoscopy, Berlin 2012
Polypectomy Technique for
Diminutive Lesions
Quality in Endoscopy: Colonoscopy, Berlin 2012
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
Quality in Endoscopy: Colonoscopy, Berlin 2012
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
Quality in Endoscopy: Colonoscopy, Berlin 2012
Quality in Endoscopy: Colonoscopy, Berlin 2012
Quality in Endoscopy: Colonoscopy, Berlin 2012
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
Quality in Endoscopy: Colonoscopy, Berlin 2012
Cold Snare: no lift
Quality in Endoscopy: Colonoscopy, Berlin 2012
Tip: Use mini-snare
Quality in Endoscopy: Colonoscopy, Berlin 2012
Quality in Endoscopy: Colonoscopy, Berlin 2012
Definitive resection?
Quality in Endoscopy: Colonoscopy, Berlin 2012
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
Quality in Endoscopy: Colonoscopy, Berlin 2012
Hot Snare, no lift
Tip: Using heat- tent the mucosa
Quality in Endoscopy: Colonoscopy, Berlin 2012
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’?
Quality in Endoscopy: Colonoscopy, Berlin 2012
Cold Snare: Lift
Quality in Endoscopy: Colonoscopy, Berlin 2012
Quality in Endoscopy: Colonoscopy, Berlin 2012
Hot Snare Lift
Tip: Always close the snare yourself
Quality in Endoscopy: Colonoscopy, Berlin 2012
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
Quality in Endoscopy: Colonoscopy, Berlin 2012
• 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)
Quality in Endoscopy: Colonoscopy, Berlin 2012
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
Quality in Endoscopy: Colonoscopy, Berlin 2012
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
Quality in Endoscopy: Colonoscopy, Berlin 2012