Management of small and diminutive polyps

Cold forceps are an appropriate tool for resection of 1-3-mm polyps that can be engulfed in a single bite. Jumbo and large-capacity forceps are more likely to engulf a tiny polyp in a single bite and are more effective and efficient than standard-size forceps. Cold snaring (transection of a polyp by guillotining without the use of electrocautery current) is more effective than either cold or hot forceps for resection of small polyps and can be used for polyps 1-9 mm in size. The size at which hot snaring (the use of snare and cautery in the traditional manner for polypectomy) should be used is unknown, but the author often uses hot snaring for pedunculated polyps, bulky sessile polyps, and proximal colon serrated polyps that are 6-9 mm in size. The cold snaring technique involves grasping a rim of normal tissue around the polyp and does not require tenting, and is therefore fundamentally different than hot snaring. Hot forceps should only be used for polyps ≤5 mm in size, it can leave residual polyp and create a thermal injury that risks delayed hemorrhage and rarely perforation. The author never uses hot forceps. The current paradigm of diminutive polyp (polyps ≤5 mm in size) management is to resect and send for pathologic evaluation. The pathology (adenoma vs hyperplastic) following removal is used to guide the postpolypectomy surveillance interval. Polyps in this size range very rarely have cancer, and infrequently have either villous elements or high-grade dysplasia. This observation has generated interest in developing endoscopic imaging technologies that could serve as alternatives to the pathologist's examination of diminutive polyps and would be less expensive than the histologic evaluation. The American Society for Gastrointestinal Endoscopy has recommended minimum performance thresholds for imaging technologies with regard to 2 clinically relevant end points: (1) a policy of “resect and discard” for high-confidence interpretations of diminutive polyps anywhere in the colon and (2) leaving distal colon hyperplastic polyps in place without resection. Several technologies appear promising with regard to reaching the recommended performance thresholds, and additional study of how well they function when used by community endoscopists is awaited.     

Prevalence of clinically important histology in small adenomas.

BACKGROUND & AIMS: The prevalence of advanced histology in small polyps has become a crucial issue in optimizing colorectal cancer screening strategies, especially in view of the advent of computed tomography colonography. We evaluated the prevalence of advanced histology in small and diminutive adenomas to clarify their clinical importance in terms of malignant potential. METHODS: Data were reviewed retrospectively from 3291 colonoscopies performed on asymptomatic patients found to have an adenoma on screening with flexible sigmoidoscopy a few weeks before the colonoscopy or who had a family history of colorectal cancer. All polyps were excised endoscopically and sent for pathology testing. Specimens with advanced histology were confirmed by a second reading. RESULTS: Of the 3291 colonoscopies performed, 1235 colonoscopies yielded a total of 1933 small or diminutive adenomatous polyps. Advanced histology including carcinoma was found in 10.1% of small (5-10 mm) adenomas and in 1.7% of diminutive adenomas (< or = 4 mm). Carcinoma was found in .9% of small adenomas, and 0% of diminutive adenomas. Of the 107 patients found to have polyps 2-10 mm with advanced histology, 100 (93%) were referred for colonoscopy because of an adenoma found on a recent screening with flexible sigmoidoscopy. Seven patients underwent colonoscopy for a positive family history of colon cancer; all 7 had a single affected first-degree relative older than age 50. CONCLUSIONS: Adenomas 5-10 mm in size harbor pathologically significant histology, and the need for removal of these lesions must be addressed to optimize colorectal cancer prevention.     

Advances in the removal of diminutive colorectal polyps

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.     

Virtual colonography: Identification and differentiation of colorectal lesions using multi-detector computed tomography

Objective. Early detection of precancerous or malignant lesions may be decisive for prognosis of patients with colorectal cancer. In this prospective feasibility study, multi-detector spiral computed tomography (CT) colonography was compared with conventional colonoscopy for the detection of colorectal polyps. Material and methods. Seventy-eight patients underwent CT colonography (standard colonoscopy preparation, distension with room air, prone and supine position) immediately before colonoscopy. Sixty-five (83%) were asymptomatic screening subjects, while the rest had symptoms suggestive of colorectal disease. Presence, location, and size of lesions were prospectively assessed. Sensitivity, specificity, and positive and negative predictive values of CT colonography were calculated using conventional colonoscopy as the reference standard. Results. Conventional colonoscopy was normal in 52 patients. In 26 patients a total of 49 polyps and 3 carcinomas were identified. All three carcinomas and 39 polyps (80%) were identified by CT colonography. Seven of 7 polyps ≥10 mm (100%), 13 of 16 polyps of 6 to 9 mm (81%), and 19 of 26 polyps ≤5 mm (73%) in diameter were identified. Fourteen false-positive findings (10 of which were ≤5 mm in diameter) were related to 8 patients (specificity at the patient level was 86%). In 10 patients, a total of 10 polyps were missed by CT colonography, 7 of which were ≤5 mm in diameter. Conclusions. In this feasibility study, multi-detector spiral CT colonography allows accurate detection of polyps>5 mm in diameter, but at the expense of low specificity in the small size range.     

The mean number of adenomas per procedure should become the gold standard to measure the neoplasia yield of colonoscopy: A population-based cohort study

BackgroundMeasuring adenoma detection is a priority in the quality improvement process for colonoscopy. Our aim was (1) to determine the most appropriate quality indicators to assess the neoplasia yield of colonoscopy and (2) to establish benchmark rates for the French colorectal cancer screening programme.MethodsRetrospective study of all colonoscopies performed in average-risk asymptomatic people aged 50–74 years after a positive guaiac faecal occult blood test in eight administrative areas of the French population-based programme.ResultsWe analysed 42,817 colonoscopies performed by 316 gastroenterologists. Endoscopists who had an adenoma detection rate around the benchmark of 35% had a mean number of adenomas per colonoscopy varying between 0.36 and 0.98. 13.9% of endoscopists had a mean number of adenomas above the benchmark of 0.6 and an adenoma detection rate below the benchmark of 35%, or inversely. Correlation was excellent between mean numbers of adenomas and polyps per colonoscopy (Pearson coefficient r = 0.90, p < 0.0001), better than correlation between mean number of adenomas and adenoma detection rate (r = 0.84, p = 0.01).ConclusionThe mean number of adenomas per procedure should become the gold standard to measure the neoplasia yield of colonoscopy. Benchmark could be established at 0.6 in the French programme.     

Clinical utility of the SMSA grading tool for the management of colonic neoplastic lesions

BackgroundWhilst polyp size has been traditionally used as a predictor of the complexity of endoscopic resection, the influence of other factors is increasingly recognised. The SMSA grading system takes into account polyp Site, Morphology, Size and Access, with higher scores correlating with increased technical difficulty.AimsTo evaluate whether the SMSA grading tool correlates with endoscopic and clinical outcomes.MethodsThis retrospective study was conducted at two high volume centres in the United Kingdom and Italy. All polyps identified at colonoscopy were included in this study and classified as per the SMSA grading system.ResultsA total of 1668 lesions were resected in 1016 patients. There was a positive correlation between increasing SMSA level and the inability to resect lesions “en bloc” (p < 0.001). Histologically complete clearance was higher in the lower SMSA groups (p < 0.0001). Additional endoscopic therapies, were more commonly required with the higher SMSA groups to achieve histological clearance (p < 0.0001). Moreover, advanced histology in resection specimens and procedural complications were significantly less common in SMSA level 1 lesions compared to level 3 or 4 lesions (p < 0.0001).ConclusionsThe SMSA grading tool is a useful predictor of outcome following the resection of colonic neoplastic lesions.     

Serrated polyps of the colon and rectum: Remove or not?

In recent years, the serrated neoplasia pathway where serrated polyps arise as a colorectal cancer has gained considerable attention as a new carcinogenic pathway. Colorectal serrated polyps are histopathologically classified into hyperplastic polyps(HPs), sessile serrated lesions, and traditional serrated adenomas; in the serrated neoplasia pathway, the latter two are considered to be premalignant. In western countries, all colorectal polyps, including serrated polyps, apart from diminutive rectosigmoid HPs are removed. However, in Asian countries, the treatment strategy for colorectal serrated polyps has remained unestablished. Therefore, in this review, we described the clinicopathological features of colorectal serrated polyps and proposed to remove HPs and sessile serrated lesions ≥ 6 mm in size, and traditional serrated adenomas of any size.     

Surveillance after positive colonoscopy based on adenoma characteristics

BackgroundPatients with adenomatous polyps are at increased risk for developing colorectal cancer based on the characteristics and number of polyps, but less is known about the individual and combined contribution of these factors. This study aimed to better characterize the risk of advanced adenoma and cancer in patients with positive baseline colonoscopy.MethodsPatients who had polyps at baseline colonoscopy were included in this retrospective cohort study (N = 1165) and were categorized into 6 groups: (1) 1–2 non-advanced adenomas (NAA’s), (2) ≥3 NAA’s, (3) advanced tubular adenoma, (4) small tubulovillous adenoma (TVA), (5) large TVA and (6) multiple advanced adenomas (MAA’s). Findings at surveillance colonoscopy were documented in each group.ResultsThe combined incidence of advanced adenoma, ≥3 NAA’s, and colorectal cancer at surveillance colonoscopy was significantly higher in the baseline large TVA (29.2%) than small TVA groups (13.5%, P < 0.001), as well as in the MAA’s group (44.1%) compared with large TVA group (P = 0.02). The incidence of colorectal cancer, however, was not significantly different between the groups.ConclusionsThe size of the polyp and the number of advanced lesions are more important than its histology for predicting the risk of high-risk metachronous lesions at follow-up.     

Interobserver agreement among endoscopists on evaluation of polypoid colorectal lesions visualized with the Pentax i-Scan technique

Background and aimsAdvances in colonoscopy, such as the Pentax i-Scan electronic technique, have the potential to improve the early detection of colorectal cancer. The aim of this multicentre study was to assess the interobserver agreement in the visualization of the surface and margins of colorectal polyps and in distinguishing neoplastic from non-neoplastic polyps.Patients and methodsEight expert endoscopists examined 400 mixed previously recorded images of polyps taken with different Pentax i-Scan settings in order to give an evaluation of the surface of the polyp and regular colonic mucosa, the pit-pattern and the nature of the lesion.ResultsA total of 400 mixed images of polyps with a diameter >5 mm and <10 mm were stored for analysis. Overall, there was a K_f agreement of 0.370 (p < 0.001) and 0.306 (p < 0.001) regarding pit-pattern and margins, respectively. The K_f agreement for the difference between neoplastic and non-neoplastic lesions was of 0.446 (p < 0.001).ConclusionsWe observed good interobserver agreement in the evaluation of neoplastic and non-neoplastic lesions and poor agreement in the evaluation of pit-pattern and margins. Adequate training is required in order to interpret images acquired with the i-Scan technique.     

Narrow-band imaging observation of colorectal lesions using NICE classification to avoid discarding significant lesions

AIM: To assess the risk of failing to detect diminutive and small colorectal cancers with the “resect and discard” policy.METHODS: Patients who received colonoscopy and polypectomy were recruited in the retrospective study. Probable histology of the polyps was predicted by six colonoscopists by the use of NICE classification. The incidence of diminutive and small colorectal cancers and their endoscopic features were assessed.RESULTS: In total, we found 681 cases of diminutive (1-5 mm) lesions in 402 patients and 197 cases of small (6-9 mm) lesions in 151 patients. Based on pathology of the diminutive and small polyps, 105 and 18 were non-neoplastic polyps, 557 and 154 were low-grade adenomas, 18 and 24 were high-grade adenomas or intramucosal/submucosal (SM) scanty invasive carcinomas, 1 and 1 were SM-d carcinoma, respectively. The endoscopic features of invasive cancer were classified as NICE type 3 endoscopically.CONCLUSION: The risk of failing to detect diminutive and small colorectal invasive cancer with the “resect and discard” strategy might be avoided through the use of narrow-band imaging observation with the NICE classification scheme and magnifying endoscopy.     

Detection rate and proximal shift tendency of adenomas and serrated polyps: a retrospective study of 62,560 colonoscopies

Purpose

The purpose of this study is to estimate the detection rates of adenomas and serrated polyps and to identify proximalization and associate risk factors in patients from Southern China.

Methods

Consecutive patients undergoing colonoscopy from 2004 to 2013 in Guangzhou were included. The proportions of proximal adenomas to advanced adenomas and serrated polyps were compared and potential predictors were evaluated.

Results

Colonoscopies (n?=?62,560) were performed, and 11,427 patients were diagnosed with polyps. Detection rates for adenomas, hyperplastic polyps, and serrated adenomas were 12.0, 2.5, and 0.2 patients per 100 colonoscopies. When comparing the 1st (2004–2008) to the 2nd period (2009–2013), adenoma and serrated polyp detection in proximal and distal colon both increased significantly (proximal colon [adenoma 3.9 vs. 6.1 patients/100 colonoscopies, P?<?0.001; serrated polyp 0.4 vs. 1.1 patients/100 colonoscopies, P?<?0.001]; distal colon [adenoma 6.6 vs. 7.2 patients/100 colonoscopies, P?=?0.003; serrated polyp 1.2 vs. 2.4 patients/100 colonoscopies, P?<?0.001]). Advanced adenoma detection increased over these two periods only in proximal colon (1st vs. 2nd period: 1.5 vs. 2.4 patients/100 colonoscopies, P?<?0.001), not the distal colon (P?=?0.114). Multivariate analyses showed that diagnostic period was an independent predictor for adenoma proximalization (OR?=?1.36, 95% CI 1.25–1.48, P?<?0.001), but not for advanced adenomas (P?=?0.117) or serrated polyps (P?=?0.928).

Conclusions

Adenomas and serrated polyps were increasingly detected throughout the colon, whereas advanced adenomas were only in proximal colon. A proximal shift tendency detected by colonoscopy was observed for adenomas, but not advanced adenomas or serrated polyps, in Southern China. The screening for proximal polyps should be emphasized and colonoscopy might be a preferred initial screening tool.

     

Development of knowledge-based clinical decision support system for patients included in colorectal screening program

Background & aimsColorectal (CRC) screening programs represent a large volume of procedures that need a follow-up endoscopy. A knowledge-based clinical decision support system (K-CDSS) is a technology which contains clinical rules and associations of compiled data that assist with clinical decision-making tasks. We develop a K-CDSS for management of patients included in CRC screening and surveillance of colorectal polyps.MethodsWe collected information on 48 variables from hospital colonoscopy records. Using DILEMMA Solutions Platform © (https://www.dilemasolution.com) we designed a prototype K-CDSS (PoliCare CDSS), to provide tailored recommendations by combining patients data and current guidelines recommendations. The accuracy of rules was verified using four scenarios (normal colonoscopy, lesions different than polyps, non-advanced adenomas and advanced adenomas). We studied the degree of agreement between the clinical assessments made by expert doctors and nurses equipped with PoliCare CDSS. Two experts confirmed a correlation between guidelines and PoliCare recommendations.Results56 consecutive endoscopy cases from colorectal screening program were included (62.8 years; range 53-71). Colonoscopy results were: absence of colon lesions (n = 7, 12.5%), lesions in the colon that are not polyps (n = 3, 5.4%) and resected colonic polyps (n = 46, 82.1%; 100% R0 resection). Patients with resected polyps presented non-advanced adenoma (n = 21, 45.6%) or advanced lesions (n = 25, 54.4%). There were no differences in erroneous orders with PoliCare CDSS (Kappa value 1.0).ConclusionsPoliCare CDSS can easily be integrated into the workflow for improving the overall efficiency and better adherence to evidence-based guidelines.     

Risk of colorectal neoplasia in patients with celiac disease: A multicenter study

Background and aimsThe association of celiac disease with colorectal neoplasia is controversial. The aim of this study was to determine the risk of colorectal neoplasia among patients with celiac disease.MethodsWe carried out a multicenter, retrospective case–control study, within four community hospitals. Celiac disease patients with a complete colonoscopy were regarded as cases and those without celiac disease as controls. For each case, two controls matched for age, sex, indication for colonoscopy and colorectal cancer family history, were randomly selected. The main outcome evaluated was risk of colorectal polyps, adenomas, advanced neoplastic lesions and cancer.ResultsWe identified 118 patients with celiac disease and 236 controls. The risk of polyps, adenomas and advanced neoplastic lesions was similar in both groups (OR 1.25, CI 0.71–2.18, p = 0.40; OR 1.39, CI 0.73–2.63, p = 0.31; and OR 1.00, CI 0.26–3.72, p = 1.00, respectively). On multivariate analysis, age > 75 years old, and first-grade CRC family history were associated with adenomas (OR 2.68 CI 1.03–6.98, OR 6.68 CI 1.03–47.98 respectively) and advanced neoplastic lesions (OR 15.03, CI 2.88–78.3; OR 6.46 CI 1.23–33.79, respectively). With respect to celiac disease characteristic, a low adherence to a gluten free diet was independently associated with the presence of adenomas (OR 6.78 CI 1.39–33.20 p = 0.01).ConclusionsCeliac disease was not associated with an increased risk of colorectal neoplasia. Nonadherence to a strict gluten free diet was associated with the presence of adenomas. Further studies addressing celiac disease characteristics are needed to confirm this observation.     

Endoscopic resection for superficial colorectal neoplasia in Italy: A prospective multicentre study

BackgroundSince there are few prospective studies on colorectal endoscopic resection to date, we aimed to prospectively assess safety and efficacy of endoscopic resection in a cohort of Italian patients.MethodsProspective multicentre assessment of resection of sessile polyps or non-polypoid lesions ≥ 10 mm in size or smaller (if depressed). Outcome measures included complete excision, morbidity, mortality, and residual/recurrence at 12 months.ResultsOverall, 1012 resections in 928 patients were analysed (62.4% sessile polyps, 28.8% laterally spreading tumours, 8.7% depressed non-polypoid lesions). Lesions were prevalent in the proximal colon. Enbloc resection was possible in 715/1012 cases (70.7%), whereas piecemeal resection was required in 297 (29.3%). Endoscopically complete excision was achieved in 866 cases (85.6%). Adverse events occurred in 83 (8.2%), and no deaths occurred. Independent predictors of 12-month residual/recurrence were the location of the lesion in the proximal colon (OR 2.22 [95% CI 1.16–4.26]; p = 0.015) and piecemeal endoscopic resection (OR 2.76 [95% CI 1.56–4.87]; p = 0.0005). Limitations of the study were: potential expertise bias, no data on eligible and potentially resectable excluded lesions, high percentage of lesions < 20 mm, follow-up limited to 1 year.ConclusionIn this registry study the endoscopic resection of colorectal lesions was safe and achieved high rates of long-term endoscopic clearance.     

Pólipos gástricos: análisis retrospectivo de 41.253 endoscopias digestivas altas

Introduction

Gastric polyps are usually asymptomatic lesions incidentally discovered during endoscopy.

Diminutive polyps of large bowel should be an early target for endoscopic treatment

BACKGROUND AND AIMS: Aim of the present study is to ascertain the importance of diminutive colorectal polyps and define the need for removal according to their characteristics and malignant potential. PATIENTS AND METHODS: A total of 4,723 patients who underwent colonoscopy were evaluated and 624 patients with 826 polyps were recorded. There were 352 patients with 443 diminutive polyps, studied according to their distribution. Of these, 371 were removed, histologically examined and correlated to patient characteristics and occurrence of synchronous neoplasms. RESULTS: Of the right colon polyps, 81/115 were diminutive, versus 362/711 of the left colon (p<0.0001). Adenomas were more common in patients over 50 years of age, (p<0.0001). In all colonic segments, diminutive adenomas prevailed over hyperplastic polyps, whereas the proportion of diminutive adenomas predominated in the right colon (p=0.0015). Adenomas were classified as tubular 39%, tubulovillous 55.7% and villous 5.3%. The degree of dysplasia was mild in 45.5%, moderate in 51% and severe in 3.5%. The prevalence of synchronous neoplasms was 37.4%. They were more frequently found in males over 50 years of age and in patients with diminutive adenomas compared to those with diminutive hyperplastic polyps (p=0.0078). CONCLUSIONS: The majority of right colon polyps are diminutive. The proportion of diminutive adenomas is higher in patients over 50 years and in the right vs left colon. Diminutive polyps should be removed taking into account the high prevalence of adenomas with a villous component and their significant degree of dysplasia.     

High-definition with i-Scan gives comparable accuracy for detecting colonic lesions by non-expert and expert endoscopists

BackgroundLesion detection rate during colonoscopy may be influenced by the endoscopist's experience. EPK-i system colonoscopy (i-Scan) can improve mucosal and vascular visualization for detecting lesions.AimTo compare mucosal lesions detection rate and the withdrawal time of the instrument among non-expert and expert endoscopists.MethodsColonoscopy records of all consecutive patients undergoing first HD+ with i-Scan- or SWL-equipped colonoscopy for colorectal cancer screening over a twelve-month period were evaluated, in a “post hoc” analysis.Results542 colonoscopies (389 HD+ with i-Scan; 153 SWL): expert and non-expert endoscopists did respectively 272 and 117 HD+ with i-Scan and 83 and 70 SWL colonoscopies. Expert endoscopists did more i-Scan colonoscopies than non-experts (p = 0.006). In the SWL procedures, the experts detected mucosal lesions in more colonoscopies than non-experts (61/22 vs. 23/47, p = 0.0001) and found a significantly higher mean number of lesions (1.34 vs. 0.47; p = 0.0001). Experts detected more or less the same mean number of lesions with both imaging techniques, while among non-experts detection with HD+ with i-Scan was significantly better than with SWL imaging (1.39 vs. 0.47; p = 0.0001).ConclusionsHD+ with i-Scan imaging enables less skilled endoscopists to achieve results comparable to those of experienced ones in detecting mucosal lesions.     

Reinterpretation of histology of proximal colon polyps called hyperplastic in 2001

AIM： To evaluate how proximal colon polyps interpreted as hyperplastic polyps in 2001 would be interpreted by expert pathologists in 2007.
METHODS： ≥ 5 mm in interpreted pathologists 2007 by 3 GI Forty consecutive proximal colon polyps size, removed in 2001, and originally as hyperplastic polyps by general at Indiana University, were reviewed in pathologists.
CONCLUSION： Many polyps interpreted as hyperplastic in 2001 were considered sessile serrated lesions by GI pathologists in 2007, but there is substantial inter-observer variation amongst GI pathologists.     

Random biopsies during surveillance colonoscopy increase dysplasia detection in patients with primary sclerosing cholangitis and ulcerative colitis

Background and aimPatients with primary sclerosing cholangitis (PSC) and ulcerative colitis (UC) are at increased risk of colon dysplasia. The role of random vs. target biopsies in these patients has not been investigated. Our aim was to evaluate the yield and clinical impact of random biopsies during surveillance colonoscopies in patients with PSC–UC.MethodsData from 71 patients (267 colonoscopies) with PSC and UC, who underwent surveillance colonoscopies and followed-up from 2001 to 2011 was obtained. Colonoscopy and pathology reports were reviewed to assess the yield of random biopsies.ResultsA total of 3975 (median 12) random biopsies were taken during surveillance colonoscopies. Overall, neoplasia was detected in 22 colonoscopies (16 patients): in 8 colonoscopies (36.4%) by targeted biopsies only and in 4 (18.2%) by both targeted and random biopsies. Neoplasia was detected in random biopsies only in 10 (45.5%) colonoscopies in 8 patients. On multivariate analysis, duration of UC (Odds ratio [OR] = 1.40; 95% confidence interval [CI], 1.08–1.81; P = 0.01), number of random biopsies (per increase by 8) (OR = 1.64; 95% CI, 1.18–2.28; P = 0.003) and target biopsies during colonoscopy (OR = 9.08; 95% CI, 3.18–26.0; P < 0.001) independently predicted the presence of dysplasia; endoscopic features of prior inflammation did not.ConclusionsRandom biopsies significantly increase the yield of dysplasia in patients with PSC and UC even in the absence of endoscopic features of prior inflammation and significantly impact clinical outcomes.