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. (C) 2013 Elsevier Inc. All rights reserved.