What is the next step in managing a sessile Paris IIa polyp smaller than 5 mm in the stomach after a cold forceps biopsy (Cold Forceps Biopsy) has been performed?

Management of Sessile Paris IIa Gastric Polyp <5mm After Cold Forceps Biopsy

Complete endoscopic resection of the polyp is necessary because cold forceps biopsy has unacceptably high rates of incomplete resection (9-61%) and cannot reliably establish the correct histological diagnosis of gastric polyps.

Why Cold Forceps Biopsy is Inadequate

Cold forceps biopsy of gastric polyps has fundamental limitations that make it insufficient for definitive management:

• Incomplete resection rates are extremely high, ranging from 9% to 61% for diminutive lesions, even when using large-capacity forceps 1
• Diagnostic accuracy is poor: Studies show complete agreement between forceps biopsy and final histology in only 55-56% of gastric polyps, with clinically important disagreements occurring in 2.7-21% of cases 2, 3
• Critical diagnoses are missed: Forceps biopsy fails to identify foci of carcinoma within hyperplastic polyps and cannot accurately grade dysplasia in adenomatous lesions 2, 3
• Multiple bites disrupt visualization: The mucosal surface disruption and bleeding from the first biopsy interfere with subsequent assessment of complete resection 1

Recommended Next Step: Complete Polypectomy

Perform cold snare polypectomy to achieve complete en bloc resection with a 1-2mm margin of normal surrounding tissue 1, 4:

Technical Approach for Cold Snare Polypectomy

1. Position the polyp at the 5 o'clock position in line with the colonoscope accessory channel 1

2. Engage the snare tip against the mucosa on the proximal side of the lesion and open slowly 1

3. Open the snare to capture 1-2mm of normal surrounding tissue while moving the endoscope slightly distally 1, 4

4. Apply gentle downward pressure with the endoscope tip deflected downward while closing the snare slowly and steadily—do not tent the polyp upward 1

5. Maintain forward pressure during closure to avoid snare slippage away from the submucosa 1

6. Complete the resection by fully closing the snare once normal tissue margins are secured 1

Why Cold Snare is Superior

• Complete resection rates of 98.2% for polyps 4-9mm, compared to 9-61% incomplete resection with cold forceps 1
• Captures normal tissue margins mechanically by ensnaring a few millimeters of normal mucosa around the polyp perimeter 1
• No electrocautery risk and no instances of postpolypectomy bleeding requiring intervention in randomized trials 1
• Allows en bloc resection for accurate histopathological analysis and confirmation of complete removal 1

Critical Pitfalls to Avoid

Do not rely on forceps biopsy alone for gastric polyps, as this approach:

• Leaves residual neoplastic tissue in 45-91% of cases 1, 2
• Cannot differentiate between hyperplastic polyps with focal carcinoma versus pure hyperplastic lesions 2, 3
• Fails to accurately grade dysplasia in adenomatous polyps in up to 25% of cases 2

Do not use hot biopsy forceps, which have high incomplete resection rates, inadequate histopathologic specimens, and increased complication rates 1

Rationale for Complete Resection

Gastric epithelial polyps require complete removal because:

• Neoplastic polyps have direct malignant potential and are most commonly solitary and antral 5
• Forceps biopsy specimens are of limited accuracy for establishing correct diagnosis, making management based solely on biopsy controversial 2, 3
• Complete resection provides definitive diagnosis and treatment in a single procedure 2, 3

Minor post-cold snare oozing is expected and self-limiting 1.