What is the policy for cis-carcinoid (carcinoid tumor) polyps less than 10 millimeters in the right colon?

From the Guidelines

For cis-alcerative polyps less than 10 millimeters in the right colon, cold snare polypectomy (CSP) is the recommended removal technique due to its high complete resection rates and low risk of complications, as supported by recent evidence 1.

Key Considerations for Polyp Removal

• The risk of high-grade dysplasia or cancer in diminutive (<5 mm) and small (6–9 mm) polyps is quite low, making CSP a safe option for removal 1.
• CSP has been shown to have high complete resection rates, with one randomized controlled trial reporting a 98.2% complete resection rate for polyps 4–9 mm in size, and no instances of post-polypectomy bleeding requiring endoscopic intervention 1.
• The technique of CSP differs from hot snare polypectomy (HSP), and involves positioning the polyp at the 5:00 position, opening the snare with the tip against the mucosa proximal to the polyp, and applying gentle pressure against the mucosa while closing the snare 1.
• Post-polypectomy oozing is common but usually ceases spontaneously, and the specimen can typically be retrieved by suctioning into a trap 1.

Additional Recommendations

• After removal, the polyp should be retrieved and sent for histopathological examination to confirm complete excision and rule out high-grade dysplasia or early malignancy.
• The right colon's thinner wall requires particular care during polypectomy to avoid perforation.
• Patients should be informed about potential delayed bleeding (up to 14 days post-procedure) and instructed to seek medical attention if they experience significant rectal bleeding, severe abdominal pain, or fever.
• Surveillance colonoscopy should be performed in 3-5 years depending on the patient's risk factors.

From the Research

Policy for Cis-Alcerative Polyps Less Than 10 Millimeters in the Right Colon

• The policy for managing cis-alcerative polyps less than 10 millimeters in the right colon is primarily based on the size and type of the polyp.
• For polyps less than 10 mm, cold snare polypectomy (CSP) is considered an effective and safe method for removal, as shown in studies 2, 3, 4.
• CSP has been found to have a high success rate for en-bloc resection, with a pooled rate of 99.7% (CI 99.1-99.9; I2 0%) in one study 2.
• However, the choice between CSP and hot snare polypectomy (HSP) may depend on factors such as the polyp's location, size, and histology, as well as the physician's preference and expertise.
• For polyps in the right colon, one study 2 found that the frequency of immediate bleeding was significantly higher, which may influence the choice of removal method.
• The American Society for Gastrointestinal Endoscopy (ASGE) and other professional organizations recommend that polyps less than 10 mm be removed using CSP or HSP, depending on the specific circumstances 5.

Removal Methods

• Cold snare polypectomy (CSP) is a recommended method for removing small polyps (<10 mm) in the right colon, due to its high success rate and low risk of complications 2, 3, 4.
• Hot snare polypectomy (HSP) is also an effective method, but it may be associated with a higher risk of bleeding and other complications compared to CSP 2, 3.
• The choice between CSP and HSP should be based on the individual patient's circumstances and the physician's expertise.

Special Considerations

• Polyps with serrated histology are more prone to incomplete resection compared to adenomas, and may require special consideration when choosing a removal method 4.
• The location of the polyp in the right colon may also influence the choice of removal method, due to the higher frequency of immediate bleeding in this location 2.