Multiple techniques exist for the management of colorectal polyps. Recent ESGE guidelines1 have defined an evidence based guide to the optimal technique for removing different sizes of polyps. Previously this decision often depended on an individual operator’s experience and training. We sought to examine current polypectomy practice amongst United Kingdom endoscopy trainees with to these guidelines.Methods
The ESGE polypectomy guideline1 suggests polyps<10 mm should be removed using cold snare polypectomy (CSP) or cold biopsy forceps (CBF) [≤3 mm only], 10–19 mm using endoscopic mucosal resection (EMR) or hot snare polypectomy (HSP) and ≥20 mm using EMR. The JETS database is a prospectively collected record of trainee colonoscopic procedures in the United Kingdom and its use during training is mandatory for accreditation. Data is entered by trainees on their own endoscopic procedures. Adverse events were classified as delayed bleeding or delayed perforation. We retrospectively analysed procedures entered into the JETS database from Jan 2008 to December 2017 for polypectomy technique and compared this to the 2017 ESGE guideline.Results
2 91 778 polypectomies were performed in 1 76 569 trainee-performed procedures by 3395 trainees over the study period. 10 584 polypectomies were missing data. 2 81 194 polypectomies were analysed.Results
Of 2 50 783 polyps<10 mm in size removed, 29.5% were performed using CBF, 27.9% by CSP, 25.1% by HSP, 9.5% by HBF, and 8.0% by EMR. Of 26 605 polyps 10–19 mm in size, 55.3% were removed by HSP, 31.0% by EMR and 3.5% by CSP. 8.4% of lesions were biopsied and not removed. Of 3806 polyps≥20 mm in size, 39.4% were removed by EMR, 36.3% by HSP, 1.1% were removed by CSP and 21.9% of these lesions were biopsied and not removed. Overall, adherence to the ESGE guidance was observed in 1 54 948 polypectomies (55.1%). Nurse endoscopists were more adherent (61.7%), versus physicians (57.9%) versus surgeons (44.3%), p<0.001.Results
Of 219 (0.1%) adverse events reported amongst all polypectomies, 50.8% were amongst HSP, 19.2% EMR, 16.9% CSP and 12.7% after HBF p<0.001. Of 20 delayed perforations (event rate 0.01%), 55% were due to EMR, 30% to HSP and 15% to HBF. No perforations resulted from CSP.Conclusions
Cold snare polypectomy is under-utilised for diminutive polypectomy, despite its proven safety and efficacy; its use amongst trainees should be promoted in line with ESGE guidance. Trainees are likely to follow the example of their trainers and, as such, this study likely provides an insight into current polypectomy practice in the wider UK endoscopic community. Trainees in the United Kingdom predominantly remove diminutive polyps with extremely low rates of adverse events.