The location-based resect and discard strategy for diminutive colorectal polyps: a prospective clinical study

Abstract

Background Clinical implementation of the resect-and-discard strategy has been difficult because optical diagnosis is highly operator dependent. This prospective study aimed to evaluate a resect-and-discard strategy that is not operator dependent. Methods The study evaluated a resect-and-discard strategy that uses the anatomical polyp location to classify colonic polyps into non-neoplastic or low risk neoplastic. All rectosigmoid diminutive polyps were considered hyperplastic and all polyps located proximally to the sigmoid colon were considered neoplastic. Surveillance interval assignments based on these a priori assumptions were compared with those based on actual pathology results and on optical diagnosis. The primary outcome was ≥ 90 % agreement with pathology in surveillance interval assignment. Results 1117 patients undergoing complete colonoscopy were included and 482 (43.1 %) had at least one diminutive polyp. Surveillance interval agreement between the location-based strategy and pathological findings using the 2020 US Multi-Society Task Force guideline was 97.0 % (95 % confidence interval [CI] 0.96–0.98), surpassing the ≥ 90 % benchmark. Optical diagnoses using the NICE and Sano classifications reached 89.1 % and 90.01 % agreement, respectively (P < 0.001), and were inferior to the location-based strategy. The location-based resect-and-discard strategy allowed a 69.7 % (95 %CI 0.67–0.72) reduction in pathology examinations compared with 55.3 % (95 %CI 0.52–0.58; NICE and Sano) and 41.9 % (95 %CI 0.39–0.45; WASP) with optical diagnosis. Conclusion The location-based resect-and-discard strategy achieved very high surveillance interval agreement with pathology-based surveillance interval assignment, surpassing the ≥ 90 % benchmark and outperforming optical diagnosis in surveillance interval agreement and the number of pathology examinations avoided.

Making a resect-and-discard strategy work for diminutive colorectal polyps: let's get real

“…This fear defies evidence-based rational decision-making. For example, in the current study, not a single diminutive polyp among 878 lesions had high grade dysplasia or cancer 1 . Based on literature review and our own data, the risk of invasive cancer in lesions ≤ 5 mm is 0.009 % 8 .…”

“…In this issue of Endoscopy , Taghiakbari et al report that assigning the histology of diminutive colorectal polyps by colon location alone produced greater agreement with surveillance intervals determined by pathology than surveillance intervals determined by optical diagnosis of diminutive colorectal polyps 1 . The location-based resect-and-discard (LBRD) strategy was simple: everything that is diminutive proximal to the sigmoid is considered an adenoma, and everything diminutive in the rectosigmoid is hyperplastic.…”

Serrated lesions and adenomas in colonoscopic surveillance: additive or exponential?

“…From this flows the concept that determining the pathology of each polyp becomes less important, or even irrelevant if small, and simply counting the polyps would determine the risk and hence surveillance interval. Such anatomically and numerically based approaches to surveillance intervals could significantly reduce pathology examination by 70%, despite achieving similar surveillance intervals in prospective studies [14].…”

Risk of total metachronous advanced neoplasia at surveillance colonoscopy after detection of serrated lesions: a matched case–cohort study

“…Future studies should consider including this variable as a potential confounder. At our center, overall ADR was sampled over multiple periods and was found to be consistently > 30 % [26][27][28]. Pathology-based diagnosis of serrated lesions is also subject to variability in interobserver agreement, which limits the interpretation of all serrated lesion studies [29].…”