Clinical importance of cold polypectomy during the insertion phase in the left side of the colon and rectum

Post written by Akira Teramoto, MD, from the Gastrointestinal Center, Sano Hospital, Kobe, Japan. Teramoto_headshot

We believe that all endoscopists are very familiar with this situation; small polyps are identified during insertion phase of colonoscopy without having any intention to search for them. The clinical question, whether we should resect now or later, seems to be one of the fundamental parts of colonoscopy; however, previous researches could not provide strong evidence to solve this question.

As our pilot study has revealed a significant number of hiding/missed lesions, we have hypothesized that polypectomy during insertion phase may reduce the total procedure time. Therefore, we have chosen to design a superiority trial of total procedure time instead of a non-inferiority trial of insertion time/number of polyps per patient. To minimize risk of having scope insertion difficulty, CO2 gas insufflation and cold polypectomy were used, and targets were limited to the left-sided small and diminutive polyps. As a result, we could show that this method eliminates the possibility of having any hiding + missed polyps (44.8% in control group) and reduce 15% of the total procedure time, which we believe are very encouraging results for all endoscopists to alter their strategy.

The unique term ‘hiding polyp’ was defined in this study. These are polyps seen during insertion phase that could not be found in a single withdrawal process. Fortunately, we have managed to re-identify most of the hiding lesions under a clinical trial setting, but we believe that the rate of these polyps being completely lost would be much higher in real practice, and this would affect the quality of colonoscopy. US Multi-Society Task Force recommendations for post-colonoscopy follow-up and polyp surveillance were updated recently in 2020, and the number of small adenomas has a significant role in risk stratification and deciding surveillance interval after polypectomy. Therefore, for quality assurance and time efficiency, polyps seen during insertion phase should be resected instantly.

We have discovered other facts by adopting this strategy in daily practice. First, resecting polyps during insertion phase makes you feel much more relaxed during withdrawal phase. As an endoscopist, I find that having no worries about missing or getting confused with other similar polyps on the way back makes a big difference, and I feel less exhausted after adopting this method. Second, we don’t have to wait and confirm hemostasis after CSP. By the time we see the post-polypectomy ulcer during withdrawal phase, the bleeding is mostly stopped. If we see any oozing blood at this point, this would be a clear indication for applying hemostatic clips and this may result in reduction of post-polypectomy bleeding. Third, polyps located at 12 o’clock are slightly difficult for applying snare; therefore, cold forceps may be useful for removal of diminutive lesions. We hope that our publication will be helpful to all readers.


Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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