Colonoscopic polypectomy practices in Australia.
Background: Polypectomy is the mainstay of colorectal cancer prevention 1, however there is little
consensus on optimal techniques. This study explores the link between training, experience and
case volume on polypectomy practice within Australia. Methods: A questionnaire to capture
relevant demographic, practice history and methods of polyp resection was developed and pre
tested. Polyps were categorised as left or right sided and pedunculated or sessile. They were further
broken down into 5 different size groups (<5mm, 5-9mm, 10-15mm, 16-20mm and >20mm). Polyp
management techniques included cold biopsy, hot biopsy, cold snare, hot snare, submucosal
injection with hot snare or referral to tertiary centre. The questionnaire was sent to 140
colonoscopists across Australia. Distribution of surveys commenced in June, 2012 and the final
completed survey was collected in November 2012 with the majority of surveys distributed via mail.
Data was collected anonymously and analysed using SPSS. Results: 65 questionnaires were
returned. 45 responders were Gastroenterologists, 14 Interventional Endoscopists, 5 Advanced
Trainees and one Surgeon. 40 responders had greater than 10 years experience and 28 had trained
in ERCP or advanced endoscopy. 36 performed > 500 colonoscopies per year. 44 were from a capital
city. Cold snare technique dominated other polypectomy techniques for sessile polyps <10mm
(53.8%; p=0.02) and submucosal pre injection and hot snare for sessile polyps ≥10mm (73.3%;
p<0.0001). Hot snare was the preferred technique for pedunculated polyps (65.5%; p<0.0001). The
chosen technique was not linked to experience (p>0.5), location of practice (p>0.5) or annual volume
of procedures (p>0.5). Preparedness to resect sessile right sided polyps >20mm was associated with
training in interventional endoscopy (p<0.02). Hot biopsy remains a popular choice for diminutive
polyp resection especially in colonoscopists with greater than 10 years experience. 11 (27.5%) of
colonoscopists in this group used hot biopsy as their preferred technique for left sided sessile polyps
<10mm. This compares to 3 (12%) of those with less than 10 years experience (p=0.2). Conclusions:
Polypectomy technique among colonoscopists is highly variable. Location, size and morphology of
polyp significantly influence choice of technique. There was no link between experience, location of
practice or annual volume of procedures and choice of technique. Despite known safety and
inefficacy, 2-3 hot biopsy is still frequently used especially for diminutive polyps. Scope of practice is
aligned with previous training as those trained in interventional endoscopy are more likely to
attempt removal of large right sided sessile polyps.
References
1. Zauber AG, Winawer SJ, O’Brien MJ, et al. Colonoscopic polypectomy and long-term
prevention of colorectal-cancer deaths. N Engl J Med, 2012;366:687-96.
2. Metz A, Moss A, McLeod D, Tran K, Godfrey C, Chandra A, Bourke M. A blinded comparison
of the safety and efficacy of hot biopsy forceps electrocauterization and conventional snare
polypectomy for diminutive colonic polypectomy in a porcine model. Gastrointest Endosc,
2013; 77: 484-90.
3. Vanagunas, A., Jacob P, Vakil N. Adequacy of "hot biopsy" for the treatment of diminutive
polyps: a prospective randomized trial. Am J Gastroenterol, 1989;84: 383-5.