From the Guidelines
Yes, there are clinical guidelines that do not recommend routine polypectomy for sessile serrated lesions less than 5mm in size. According to the AGA clinical practice update on appropriate and tailored polypectomy, recent evidence has shown that the risk of high-grade dysplasia or cancer in diminutive (less than 5 mm) polyps is quite low 1. The US Multi-Society Task Force on Colorectal Cancer recommends cold snare polypectomy (CSP) for all polyps less than 10 mm, but it can be technically difficult to remove some 1- to 3-mm polyps by CSP, and many endoscopists use cold forceps polypectomy (CFP) for these polyps 1. However, CFP is associated with higher incomplete polypectomy rates compared with CSP, and guidelines have generally recommended against CFP for polyps larger than 3 mm 1.
Key Considerations
- The natural history of diminutive sessile serrated lesions suggests they grow slowly, with an estimated dwell time of 10-15 years before potentially developing into cancer.
- Endoscopists should document these small lesions when identified during colonoscopy and consider factors such as the patient's age, comorbidities, and family history when deciding whether to remove them.
- In younger patients or those with a strong family history of colorectal cancer, a more aggressive approach might be warranted.
- The rationale behind this guideline is to balance the minimal cancer risk against the potential complications of polypectomy, including bleeding and perforation, while optimizing resource utilization during colonoscopy procedures.
Polypectomy Techniques
- Cold snare polypectomy (CSP) is recommended for all polyps less than 10 mm.
- Cold forceps polypectomy (CFP) can be used for 1- to 3-mm polyps, but large capacity or jumbo forceps should be used over standard forceps, and careful inspection of the polypectomy site is needed to ensure complete removal 1.
- Hot snare polypectomy (HSP) should no longer be used for polyps less than 10 mm in size due to improved complete polypectomy rates and safety profiles with CSP 1.
From the Research
Clinical Guidelines for Sessile Serrated Lesions
- There are clinical guidelines that discuss the management of sessile serrated lesions, but the provided studies do not explicitly state that polypectomy is not recommended for lesions less than 5mm in size 2, 3, 4, 5, 6.
- However, a study published in 2021 suggests that the optical criteria for diagnosing sessile serrated lesions are not reliable for diminutive lesions, which are typically less than 5mm in size 4.
- Another study from 2020 found that additional serial sections can help reclassify hyperplastic polyps as sessile serrated lesions, especially for small proximal polyps 6.
- The study from 2021 also mentions that size greater than 5mm and proximal location increase the probability of a correct diagnosis of sessile serrated lesions 4.
- It can be inferred that the management of sessile serrated lesions less than 5mm in size may be more complex and require careful consideration, but the provided studies do not provide a clear answer to the question of whether polypectomy is recommended or not for these lesions 2, 3, 4, 5, 6.
Key Findings
- Sessile serrated lesions are premalignant lesions that can progress to colorectal cancer 2, 3, 5.
- The detection and resection of sessile serrated lesions can be challenging due to their indistinct borders and small size 3, 4.
- High-quality colonoscopy and good bowel preparation are essential for improving the detection rate of sessile serrated lesions 3.
- The use of additional serial sections can help improve the accuracy of diagnosis for small hyperplastic polyps and sessile serrated lesions 6.