What is the significance of a 5-9 mm sessile polyp in the proximal transverse colon, completely removed en bloc by cold snare polypectomy (CSP)?

From the Guidelines

The complete removal of a 5-9 mm sessile polyp in the proximal transverse colon by cold snare polypectomy (CSP) is a highly effective and safe procedure, with a low risk of complications, and surveillance colonoscopy is recommended in 7-10 years, assuming this is an average-risk patient with no personal or family history of advanced neoplasia. This recommendation is based on the polyp's characteristics: it was small (less than 10 mm), sessile (flat with no stalk), and was completely removed with the cold snare technique, which is appropriate for polyps of this size, as supported by the US Multi-Society Task Force on Colorectal Cancer 1 and recent evidence from the AGA clinical practice update on appropriate and tailored polypectomy 1. The Paris Is classification indicates a slightly elevated lesion, and complete removal and specimen retrieval allows for histopathological examination, which is crucial to determine if this is a conventional adenoma, serrated lesion, or hyperplastic polyp.

Some key points to consider in the management of this patient include:

• The cold snare polypectomy technique is recommended for polyps less than 10 mm in size, due to its high complete resection rates and safety profile, as shown in a randomized controlled trial with a complete resection rate of 98.2% for polyps 4–9 mm in size 1.
• The use of hot snare polypectomy (HSP) is no longer recommended for polyps less than 10 mm in size, due to its lower complete polypectomy rates and higher complication rates compared to CSP 1.
• The technique of CSP differs from that of HSP, and ideally, the polyp should be positioned at the 5:00 position, with the snare opened with the tip against the mucosa proximal to the polyp, and gentle forward pressure and suction applied to avoid slippage of the snare during closure 1.
• Postpolypectomy oozing is common but usually ceases spontaneously, and patients should be informed about the importance of adhering to the recommended surveillance interval to prevent interval colorectal cancer.

The pathology results should guide final recommendations, as finding advanced histology (high-grade dysplasia or villous features) or serrated pathology might necessitate earlier surveillance. Overall, the management of this patient should be based on the latest evidence and guidelines, with a focus on minimizing complications and preventing interval colorectal cancer.

From the Research

Significance of a 5-9 mm Sessile Polyp

• The removal of a 5-9 mm sessile polyp in the proximal transverse colon by cold snare polypectomy (CSP) is significant because it reduces the risk of colorectal cancer 2.
• CSP is a safe and effective method for polypectomy, with a lower rate of complications compared to hot snare polypectomy (HSP) 3, 2.
• The size of the polyp (5-9 mm) is within the range where CSP is preferred, as it has been shown to be effective for polyps ≤10 mm 4, 2.

Cold Snare Polypectomy (CSP) Outcomes

• CSP has been shown to have a high complete resection rate, with low rates of incomplete resection and recurrence 5.
• The use of CSP for small polyps (<10 mm) has been associated with a lower rate of delayed bleeding and postpolypectomy syndrome compared to HSP 3, 2.
• CSP can be considered for certain lesions 11-19 mm in size, but further evidence is required to establish its safety for larger polyps 4, 6.

Clinical Implications

• The complete removal of the polyp en bloc by CSP suggests that the procedure was successful, and the risk of residual polyp or recurrence is low 5.
• The location of the polyp in the proximal transverse colon does not affect the significance of the removal, as CSP can be used for polyps in various locations in the colon 3, 2.
• Further surveillance colonoscopy may be necessary to monitor for any potential recurrence or development of new polyps 5.