Small Left-Sided Polyps Seen During Colonoscope Insertion: Remove Them When You See Them

Colorectal

Douglas K. Rex, MD, MASGE reviewing Teramoto A, et al. Gastrointest Endosc 2019 Dec 23.

Experienced colonoscopists know that when a small polyp is encountered during insertion, it is best to remove it immediately, as identifying it during withdrawal is sometimes difficult.

In a randomized controlled trial involving 1451 patients, 220 patients were eligible for randomization to either removal of a left-sided lesion <1 cm in size during insertion or saving it for removal during withdrawal. The mean actual time for intubating the cecum was similar between the two groups, but total procedural time was substantially shorter in the group with polyps removed during insertion (18.9 vs 22.3 minutes; P <0.001). In the group randomized to polyp removal during withdrawal, 44.8% required repeated examinations of the left colon to locate the polyp, and 6.5% of polyps were never found. The group that required multiple examinations and the group with entirely lost polyps resulted in reinspection times of 2.5 and 4.7 minutes, respectively.

Comment:

Clearly, removal of left-sided lesions under 1 cm in size that are seen during insertion saves time, and I would extend this recommendation to the transverse colon and distal ascending colon. It’s also safe to remove flat or subtle lesions >1 cm in size during insertion and then proceed with cecal intubation. The only caveat is that when a lesion is sighted during insertion and there is a significant loop or bend in the insertion tube, resection during insertion may be technically more difficult.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Douglas K. Rex, MD, MASGE

Bio and Disclosures

Citation(s):

Teramoto A, Aoyama N, Ebisutani C, et al. Clinical importance of cold polypectomy during the insertion phase in the left side of the colon and rectum: a multicenter randomized controlled trial (PRESECT STUDY). Gastrointest Endosc 2019 Dec 23. (Epub ahead of print) (https://doi.org/10.1016/j.gie.2019.12.019)