What is the standard procedure for a medical polypectomy?

Standard Procedure for Medical Polypectomy

The standard procedure for medical polypectomy should be tailored based on polyp size, morphology, and location, with cold snare polypectomy (CSP) being the recommended technique for polyps <10 mm in size. 1

Initial Assessment and Preparation

• A structured visual assessment using high-definition white light and/or electronic chromoendoscopy with photodocumentation should be conducted for all polyps found during colonoscopy 1
• Closely inspect colorectal polyps for features of submucosally invasive cancer using validated optical diagnosis schemas such as the NICE classification criteria 1
• Carbon dioxide insufflation is recommended instead of air during colonoscopy and endoscopic mucosal resection (EMR) to reduce post-procedure pain and distension 1
• Microprocessor-controlled electrosurgical units should be used when thermal techniques are employed 1

Polypectomy Technique Selection Based on Polyp Size

For Diminutive (≤5 mm) and Small (6-9 mm) Polyps:

• Cold snare polypectomy is the recommended technique for all polyps <10 mm in size 1
• Cold forceps polypectomy can alternatively be used for 1-3 mm polyps where cold snare polypectomy is technically difficult 1
• Hot forceps polypectomy should not be used due to risk of deep thermal injury 1
• Complete resection rates with cold snare polypectomy are excellent (98.2%) with minimal complications 1

For Intermediate-Size Polyps (10-19 mm):

• Clinicians should be familiar with various techniques including cold and hot snare polypectomy and EMR 1
• Consider using lifting agents or underwater EMR for removal of sessile polyps 10-19 mm in size 1
• For pedunculated lesions >10 mm, hot snare polypectomy is recommended 1
• Serrated polyps should be resected using cold resection techniques regardless of size 1

For Large Polyps (≥20 mm):

• Refer patients with polyps to endoscopic referral centers in the context of size ≥20 mm, challenging polypectomy location, or recurrent polyp at a prior polypectomy site 1
• Endoscopic removal should be the first-line management of benign colorectal lesions, even large ones, as it is more cost-effective and has lower morbidity and mortality compared to surgery 1

Special Considerations

For Serrated Polyps:

• Use cold resection techniques for all serrated polyps 1
• Submucosal injection may be helpful for serrated polyps >10 mm if margins cannot be well delineated 1

For Suspected Malignant Polyps:

• Refer patients with non-pedunculated polyps with clear evidence of submucosal invasive cancer for surgical evaluation 1
• Signs of invasive cancer include firm, fixed, ulcerated lesions; NICE type 3 features; Paris classification type III; and lesions that extend deeply into the appendix 1
• Limited cold forceps biopsy tissue sampling should be performed to confirm histology when cancer is suspected 1

Proper Technique for Cold Snare Polypectomy

• Position the polyp at the 5:00 position 1
• Open the snare with the tip against the mucosa proximal to the polyp 1
• Deflect the endoscope tip downward to apply gentle pressure against the mucosa while gradually closing the snare 1
• Include a 1-to-several millimeter rim of normal tissue around the polyp 1
• Fully close the snare without tenting the polyp upward during resection 1
• Postpolypectomy oozing is common but usually ceases spontaneously 1

Documentation and Follow-up

• Tattoo lesions that may need future localization at endoscopy or surgery 1
• Tattoos should be placed at 2-3 separate locations 3-5 cm distal to the lesion 1
• Document the type of resection method used in the procedure report 1
• Clips are not routinely needed to close resection sites for polyps <20 mm 1

Complications Management

• The 30-day mortality associated with endoscopic resection of large colorectal lesions is only 0.08%, compared to 0.7% with surgical resection 1
• Major complications include bleeding (most common) and perforation 2
• Endoscopic clipping techniques can be useful in cases of fresh small perforation 1
• For perforations without clinical signs of peritonitis, patients can be discharged on a conservative diet and oral antibiotics after defect closure 1

By following these evidence-based guidelines for polypectomy, endoscopists can ensure the safest, most complete, and most efficient resection of colorectal polyps, thereby reducing the risk of colorectal cancer while minimizing procedure-related complications.