When is polypectomy (polyp removal) recommended?

When is Polypectomy Recommended?

Polypectomy should be performed for all adenomatous polyps and serrated lesions detected during colonoscopy to prevent colorectal cancer, with the specific technique determined by polyp size, morphology, and features suggesting invasive cancer. 1

Primary Indications for Polypectomy

All Adenomatous Polyps Require Removal

• The primary aim of polypectomy is complete removal of colorectal lesions and subsequent prevention of colorectal cancer. 1
• Colonoscopic polypectomy has been definitively shown to reduce colorectal cancer incidence by 66-80% in multiple studies. 1
• All adenomatous polyps should be removed regardless of size, as they represent the precursor lesion to most colorectal cancers. 1

Serrated Polyps

• All serrated polyps should be resected using cold resection techniques regardless of size. 2
• Serrated polyps are frequently missed or incompletely removed and contribute to interval cancers. 3

Hereditary Polyposis Syndromes

• In Peutz-Jeghers Syndrome, elective polypectomy is recommended for small bowel polyps >1.5-2 cm in size (or smaller if symptomatic) to prevent intussusception. 1
• In Juvenile Polyposis Syndrome, colonoscopic surveillance should commence at age 15 years (or earlier if symptomatic) with 1-3 yearly intervals, removing polyps as encountered. 1

Size-Based Polypectomy Recommendations

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

• Cold snare polypectomy is strongly recommended for all polyps <10 mm due to high complete resection rates (98.2%) and excellent safety profile. 1, 2
• Cold forceps polypectomy may be used only for 1-3 mm polyps where cold snare is technically difficult, using large-capacity or jumbo forceps. 1
• Hot biopsy forceps and hot snare polypectomy should never be used for polyps <10 mm due to high incomplete resection rates and complication risks. 1

Medium-Sized Non-Pedunculated (10-19 mm) Polyps

• Cold or hot snare polypectomy (with or without submucosal injection) is recommended for 10-19 mm non-pedunculated lesions. 1
• For pedunculated lesions >10 mm, hot snare polypectomy is recommended. 2

Large Non-Pedunculated (≥20 mm) Polyps

• Endoscopic mucosal resection (EMR) is the preferred treatment method for large (≥20 mm) non-pedunculated colorectal lesions. 1
• These lesions should be managed by an endoscopist experienced in advanced polypectomy. 1
• All grossly visible tissue should be resected in a single colonoscopy session and in the safest minimum number of pieces, as prior failed attempts increase recurrence risk. 1
• Endoscopic resection has 30-day mortality of only 0.08% compared to 0.7% with surgical resection. 2

When to Avoid or Modify Polypectomy

Features Suggesting Deep Submucosal Invasion

• Endoscopists must be proficient in recognizing deep submucosal invasion before attempting resection. 1

• Features suggesting submucosal invasive cancer include:

  • NICE Type 3 classification (42% have submucosal invasion) 1
  • Paris 0-IIc morphology (depressed lesions) 1
  • Non-granular lateral spreading tumors 1
  • Kudo pit pattern Type V 1
  • Disrupted or missing vessels with amorphous surface pattern 1

• Patients with non-pedunculated polyps showing clear evidence of submucosal invasive cancer should be referred for surgical evaluation rather than attempted endoscopic resection. 2

• Limited cold forceps biopsy may be performed to confirm histology when cancer is suspected. 2

Malignant Polyps After Endoscopic Removal

• Complete endoscopic polypectomy is adequate treatment for pedunculated polyps with favorable histologic features: clear margins, well-differentiated, no lymphovascular invasion, and invasion limited to head/stalk (Haggitt level 1-2). 1
• Surgical resection is recommended when unfavorable histologic features are present: 1
  • Lymphatic or venous invasion
  • Grade 3 (poorly differentiated) carcinoma
  • Level 4 invasion (invades submucosa of bowel wall below polyp)
  • Involved margins of excision
  • Sessile polyps with invasive carcinoma (usually level 4 invasion)

Critical Technical Considerations

Pre-Resection Assessment

• Structured visual assessment using high-definition white light and/or electronic chromoendoscopy with photodocumentation should be conducted for all polyps. 2
• Document location, size in millimeters, and Paris classification morphology in the procedure report. 1
• Photo documentation is required for all lesions ≥10 mm before removal. 1

Referral Thresholds

• When an endoscopist encounters a suspected benign colorectal lesion they are not confident to remove completely, referral to an endoscopist experienced in advanced polypectomy is strongly recommended in lieu of surgical referral. 1
• Endoscopy should be the first-line management of benign colorectal lesions, as the majority can be safely and effectively removed endoscopically. 1

Post-Polypectomy Surveillance

After Piecemeal EMR (≥20 mm lesions)

• Intensive follow-up is required: first surveillance at 6 months, then at 1 year, then at 3 years. 1
• Careful examination of the post-mucosectomy scar using enhanced imaging (chromoendoscopy or electronic methods) with targeted biopsies is essential. 1

After Complete Polypectomy of Smaller Lesions

• Patients with advanced or multiple adenomas (≥3) should have first follow-up colonoscopy in 3 years. 1
• Patients with 1-2 small (<1 cm) tubular adenomas should have first follow-up colonoscopy at 5 years. 1