Colorectal polypectomy during insertion and withdrawal or only during withdrawal? A randomized controlled trial

Background and study aims: Removal of colorectal polyps is routinely performed during withdrawal of the endoscope. However, polyps detected during insertion of the colonoscope may be missed at withdrawal. We aimed to evaluate whether polypectomy during both insertion and withdrawal increases polyp detection and removal rates compared with polypectomy at withdrawal only, and to assess the duration of both approaches.

Patients and methods: Patients were included into the study when the first polyp was detected, and randomized into two groups; in group A, polyps ≤ 10 mm in diameter were removed during insertion and withdrawal of the colonoscope, while in group B, these polyps were removed at withdrawal only. Main outcome measures were duration of colonoscopy, number of polyps detected during insertion but not recovered during withdrawal, technical ease, patient discomfort, and complications.

Results: 150 patients were randomized to group A and 151 to group B. Mean (± standard deviation [SD]) duration of colonoscopy did not differ between the groups (30.8 ± 15.6 min [A] vs. 28.5 ± 13.8 min [B], P = 0.176). In group A 387 polyps (mean 2.58 per colonoscopy) were detected and removed compared with 389 polyps detected (mean 2.58 per colonoscopy) in group B of which 376 were removed (13 polyps were missed, mean size [SD] 3.2 [1.3] mm; 7.3 % of patients). Patient tolerance was similar in the two groups.

Conclusions: Removal of polyps ≤ 10 mm during withdrawal only is associated with a considerable polyp miss rate. We therefore recommend that these polyps are removed during both insertion and withdrawal.

^* The first two authors contributed equally.

• References

• 1 Fyock CJ, Draganov PV. Colonoscopic polypectomy and associated techniques. World J Gastroenterol 2010; 16: 3630-3637
• 2 Hewett DG, Kahi CJ, Rex DK. Does colonoscopy work?. J Natl Compr Canc Netw 2010; 8: 67-76
• 3 Coe S, Wallace M. Management of small and diminutive colorectal polyps: a review of the literature. Minerva Gastroenterol Dietol 2011; 57: 167-176
• 4 Rey JF, Beilenhoff U, Neumann CS et al. European Society of Gastrointestinal Endoscopy (ESGE) Guideline: the use of electrosurgical units. Endcoscopy 2010; 42: 764-772
• 5 Morris ML, Tucker RD, Baron TH et al. Electrosurgery in gastrointestinal endoscopy: principles to practice. Am J Gastroenterol 2009; 104: 1563-1574
• 6 Levin B, Lieberman DA, McFarland B et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline form the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin 2008; 58: 130-160
• 7 Theuerkauf jr FJ. Colonoscopy and polypectomy. Am Surg 1976; 42: 33-43
• 8 Rex DK, Cutler CS, Lemmel GT et al. Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies. Gastroenterology 1997; 112: 24-28
• 9 Hixson LS, Fennerty MB, Sampliner RE et al. Prospective study of the frequency and size distribution of polyps missed by colonoscopy. J Natl Cancer Inst 1990; 82: 1769-1772
• 10 Schuller JC, Mayer M, Lanz D et al. A novel diagram and complement to the CONSORT chart for presenting multimodal clinical trials. Contemp Clin Trials 2009; 30: 201-204
• 11 Brenner H, Chang-Claude J, Seiler CM et al. Protection from colorectal cancer after colonoscopy: a population-based, case-control study. Ann Intern Med 2011; 154: 22-30
• 12 Tolliver KA, Rex DK. Colonoscopic polypectomy. Gastroenterol Clin North Am 2008; 37: 229-251 , ix
• 13 Kronborg O. Colon polyps and cancer. Endoscopy 2004; 36: 3-7
• 14 Stryker SJ, Wolff BG, Culp CE et al. Natural history of untreated colonic polyps. Gastroenterology 1987; 93: 1009-1013
• 15 Hofstad B, Almendingen K, Vatn M et al. Growth and recurrence of colorectal polyps: a double-blind 3-year intervention with calcium and antioxidants. Digestion 1998; 59: 148-156
• 16 Arber N, Kuwada S, Leshno M et al. Sporadic adenomatous polyp regression with exisulind is effective but toxic: a randomised, double blind, placebo controlled, dose-response study. Gut 2006; 55: 367-373
• 17 Hur C, Chung DC, Schoen RE et al. The management of small polyps found by virtual colonoscopy: results of a decision analysis. Clin Gastroenterol Hepatol 2007; 5: 237-244
• 18 Brenner H, Hoffmeister M, Stegmaier C et al. Risk of progression of advanced adenomas to colorectal cancer by age and sex: estimates based on 840 149 screening colonoscopies. Gut 2007; 56: 1585-1589
• 19 Leung JW, Mann SK, Siao-Salera R et al. A randomized, controlled comparison of warm water infusion in lieu of air insufflation versus air insufflation for aiding colonoscopy insertion in sedated patients undergoing colorectal cancer screening and surveillance. Gastrointest Endosc 2009; 70: 505-510
• 20 Bertoni S, Sassatelli R, Conigliaro R et al. Visual “disappearing phenomenon” can reliably predict the nonadenomatous nature of rectal and rectosigmoid diminutive polyps at endoscopy. Gastrointest Endosc 1994; 40: 588-591