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Current British Society of Gastroenterology guidelines use adenomatous polyp size as one of the key factors in determining polyp follow-up. This study aimed to compare polyp size assessment by colonoscopists and pathologists before and after fixation to determine the optimal method for measurement.Thirty-five colorectal polyps were found during pre-arranged colonoscopies in one centre. Polyp size was measured to the nearest 1 mm by three different methods:by the endoscopist at colonoscopy;by the pathologist fresh, following removal;by the pathologist fixed, following fixation.The endoscopist and the pathologist were blinded to each other's measurements.Seventeen men, eighteen women with mean age of 66.2 years (SD: 9.4, range: 38.7–85.5) underwent polypectomy/s with all polyps removed intact. Polypectomies were performed by consultants (43%), nurse specialists (34%) and specialist registrars (23%).The median size (mm) of polyps measured were endoscopically, 6.5 (2–25 mm); fresh specimen 7.0 (4–28 mm) and fixed 7.0 (4–28 mm). Endoscopic measurements were significantly lower than that of fresh and fixed sizes (P < 0.001 and P = 0.003 respectively), with poor correlation [correlation of variance (CV): 21.0% and intraclass correlation coefficient (ICCC): 0.841 for endoscopic and fresh measurements; CV: 21.1% and ICCC: 0.838 for endoscopic and fixed measurements]. There was no statistical difference between fresh and fixed specimen measurements (P > 0.05; CV: 4.2%, ICCC: 0.974). In three patients, the endoscopic measurement was < 1 cm in polyps that were found to be ≥ 1 cm on pathological measurement.Endoscopists consistently underestimated polyp size. Fixation had no effect on polyp size. Pathologists’ measurement of polyp size on fixed specimens should determine the need for further colonoscopic follow-up.