Size Cut-Off for Removal of Pedunculated Polyps
Hot snare polypectomy (HSP) should be used to remove pedunculated polyps >10 mm in size, while cold snare polypectomy (CSP) can be considered for pedunculated polyps <10 mm with thin stalks. 1
Pedunculated Polyp Management Based on Size
Polyps ≤10 mm
- Cold snare polypectomy (CSP) can be safely used for small pedunculated polyps (<10 mm) with thin stalks 1
- Recent evidence suggests CSP for small pedunculated polyps has a lower risk of immediate bleeding than previously thought 2
- Choking the polyp base during CSP can significantly reduce the risk of immediate postpolypectomy bleeding by up to 97% 2
Polyps >10 mm
- Hot snare polypectomy (HSP) is recommended for pedunculated polyps >10 mm to decrease the risk of immediate bleeding 1
- Pedunculated polyps contain a feeding blood vessel within the stalk, making thermal therapy important for larger lesions 1
- Polyps should be transected low enough on the stalk to allow appropriate resection margin and pathologic evaluation 1
Risk Factors for Bleeding in Pedunculated Polyps
- Polyp size ≥10 mm is a known risk factor for bleeding 1
- Stalk diameter ≥5 mm significantly increases bleeding risk 1
- Prophylactic measures are recommended for high-risk pedunculated polyps, particularly those with:
Prophylactic Measures for High-Risk Pedunculated Polyps
For pedunculated polyps with heads ≥20 mm and/or stalks ≥5 mm, consider:
- Epinephrine injection into the stalk 1, 3
- Prophylactic placement of detachable nylon loops (Endoloop) 1, 3
- Standard clips 1
Special Considerations
- For very large pedunculated polyps (≥30 mm) with wide stalks that cannot be removed by conventional snare methods, endoscopic submucosal dissection (ESD) may be considered 4
- Prophylactic clipping is generally not recommended for polyps <20 mm regardless of location or patient anticoagulation status 1
- Referral to specialized endoscopic centers should be considered for polyps ≥20 mm or those in challenging locations 1
Malignancy Considerations
- For pedunculated polyps with suspected or confirmed malignancy, ensure complete resection with negative margins (at least 2 mm) 1
- Pedunculated malignant polyps are considered high risk if they have: poor differentiation, lymphovascular invasion, submucosal invasion >1 mm, cautery margin, or tumor budding 1
- Pedunculated polyps with cancer can often be managed endoscopically if the stalk is uninvolved, there is no lymphatic/vascular invasion, and the cancer is well-differentiated 5
By following these size-based guidelines for pedunculated polyp removal, clinicians can minimize complications while ensuring complete resection of potentially malignant lesions.