What is the appropriate management for multiple colon polyps, including tubular adenomas, found in the ileocecal valve, ascending colon, transverse colon, and descending colon, diagnosed via hot biopsy forceps (HBFP)?

From the Guidelines

For the descending colon polyps, they should be removed using cold snare polypectomy, which is the recommended method for removing diminutive and small lesions due to its high complete resection rates and safety profile 1. Based on the pattern of findings in the other segments (all showing tubular adenomas), these descending colon polyps likely represent additional adenomas that carry malignant potential. Complete removal and histological examination is essential to determine their nature and guide follow-up care. Some key points to consider when removing these polyps include:

• The use of cold snare polypectomy for diminutive and small lesions, as it has been shown to have high complete resection rates and a safe profile 1
• The importance of documenting endoscopic descriptors of the lesion, including location, size, and morphology, to facilitate histologic prediction and optimal removal strategy 1
• The use of photo documentation for all lesions 10 mm in size before removal, and consideration of photo documentation of the post-resection defect 1 After removal of all polyps, surveillance colonoscopy should be scheduled according to the findings, typically in 3-5 years for patients with multiple tubular adenomas, as recommended by the US Multi-Society Task Force on Colorectal Cancer 1. The timing depends on the number, size, and histology of all polyps found. This approach is necessary because tubular adenomas represent precancerous lesions that can progress to colorectal cancer if left untreated, and the presence of multiple adenomas throughout the colon suggests a higher risk for developing additional polyps in the future. Some key considerations for follow-up care include:
• The number and size of the polyps, with more numerous or larger polyps indicating a higher risk for recurrence or progression to cancer 1
• The histology of the polyps, with villous or high-grade dysplastic lesions indicating a higher risk for cancer 1
• The patient's family history and other clinical factors, which can influence the risk for colorectal cancer and guide follow-up care 1

From the Research

Polyp Removal Techniques

• The use of hot biopsy forceps for polyp removal is no longer recommended due to the increased risk of diathermic injury, as stated in the study 2.
• Cold snare polypectomy is the preferred method for removing polyps measuring 4-5mm, while cold biopsy polypectomy is suitable for polyps measuring 1-3mm 2.
• The study 3 explains the techniques of snare polypectomy and hot-biopsy polypectomy, but notes that the complication rate is acceptable.

Polyp Types and Removal

• Tubular adenoma polyps, such as those found in the ileocecal valve, ascending colon, and transverse colon, can be removed using cold snare polypectomy or cold biopsy polypectomy 2.
• Hyperplastic polyps, such as those found in the transverse colon, are typically non-neoplastic and can be removed using cold snare polypectomy or left in place if small 4.
• The presence of large serrated polyps is associated with an increased risk of synchronous advanced colorectal neoplasia, and their removal is recommended 4.

Specific Polyp Removal Recommendations

• For the ileocecal valve colon polyp, ascending colon polyp, and transverse colon polyp, cold snare polypectomy or cold biopsy polypectomy can be used for removal 2.
• For the descending colon polyp, the same removal techniques can be applied, but the decision to remove or leave in place should be made based on the polyp's size and characteristics 2.
• The study 5 compares the safety and efficacy of hot biopsy forceps electrocauterization and conventional snare polypectomy for diminutive colonic polypectomy, and finds that conventional snare polypectomy is a safer and more effective method.

Additional Considerations

• The resect and discard strategy and the diagnose and disregard strategy should only be performed by expert endoscopists, who should use validated scales and document the polyp features by storing several endoscopic images 2.
• The study 6 discusses the evolution of traditional serrated adenomas to tubulovillous adenomas and beyond, highlighting the importance of accurate diagnosis and removal of these polyps.