key: cord-0706226-3buxu1i5 authors: nan title: Follow‐up of small and diminutive colonic polyps—How to balance the risks in the COVID‐19 era date: 2021-09-24 journal: Colorectal Dis DOI: 10.1111/codi.15907 sha: 52a4f59e3b98978c0ae7b127ec4aa641a343f90d doc_id: 706226 cord_uid: 3buxu1i5 The COVID-19 pandemic has led to a reduced colonoscopy capacity in the UK resulting in increased waiting times for investigation. To increase diagnostic capacity and reduce the risk of diagnostic delay, CT colonography (CTC) and colon capsule endoscopy (CCE) are increasingly being relied upon. Endoscopic assessment and treatment will be required for those patients with large colonic polyps or malignant tumours detected by CTC or CCE, provided they are fit enough to undergo further investigation. The management of patients with intermediate (6-9mm) and diminutive (<6mm) colonic polyps, reported by CTC and CCE, will increasingly be decided by clinicians. Published literature suggests the risk of progression to malignancy of intermediate or diminutive polyps over 3 years is low. Furthermore, the risk of intermediate or diminutive polyps harbouring malignancy is extremely low. The benefits, and timeline, for the removal of these polyps must be carefully considered for patients. We present a pragmatic approach to managing intermediate and diminutive polyps. We suggest delayed polypectomy (up to one year) for patients with intermediate polyps who are likely to benefit. For those patients with diminutive polyps, we advocate further surveillance only for younger patients where clinical concern exists. This meets the aspirations of Realistic Medicine, providing a risk-based approach for patients, while appropriately prioritising resources. of the large bowel and colorectal cancer (CRC) is well established [2] . Polypectomy is carried out when polyps are identified at OC, to reduce the risk of CRC developing [3] . The relative risk of adverse events is greater for those undergoing therapeutic OC compared with diagnostic OC, but the absolute risk remains low [4] . Overall, for most patients the benefits of polypectomy outweigh the risks. Colonoscopy capacity in the United Kingdom has been reduced significantly due to the effects of the COVID-19 pandemic [5] . Clinicians are rightly concerned about the risk of a delayed diagnosis of CRC caused by prolonged waiting times for investigation, and the risk of COVID transmission to patients or staff involved in supporting invasive procedures. National efforts are being made to mitigate these risks [6] [7] [8] . This has led to a greater reliance on alternative colonic investigations, namely CT colonography (CTC) and colon capsule endoscopy (CCE). While accurate at detecting colonic pathology, these investigations will necessitate some patients undergoing follow-up endoscopic procedures to biopsy or treat pathology [9] . The use of the faecal immunochemical test (FIT) has also been advocated as an adjunct to clinical acumen to help triage patients, given its ability to determine the risk of patients harbouring significant bowel pathology [10] [11] [12] . CTC or CCE can therefore be used to reduce the risk of diagnostic delay in those with intermediate FIT results by providing additional diagnostic capacity [13] . Consequently, as the use of CTC and CCE increases, clinicians will more frequently have to determine how best to manage patients in whom polyps have been reported. Malignant pathology, or large polyps (≥10 mm), found by CTC or CCE, will inevitably require luminal assessment in an appropriate timeframe, provided that the patient is fit enough to undergo further investigation or therapeutics, in concordance with the principles of Realistic Medicine [14, 15] . [21] . In addition, there is an acceptance that low risk adenomas will be missed using FIT at a cut-off of 10 µg/g in symptomatic patients. Furthermore it has also been reported that the risk of subsequent CRC in this group is very low and safety netting is not being © 2021 The Association of Coloproctology of Great Britain and Ireland The members of the group 'The ScotCap Clinical Leads Collaboration' are listed in advocated [11] . Due to the nature of the test, CCE is much more likely to report diminutive polyps. Polypectomy for diminutive polyps in elderly patients is similarly difficult to justify given the low risk of the polyps progressing within the patients' lifetime. Younger patients with diminutive polyps should be encouraged to participate in a national bowel screening programme when invited; this will provide an adequate safety net. Clinicians may feel uncomfortable about leaving diminutive polyps in younger patients who are at least 5 years from the bowel screening age given the risk of progression in the longer term. Therefore, clinicians could consider offering surveillance OC within 5 years to minimize future risk. help flow. This strategy, however, assumes that the current endoscopy backlogs are reduced and further capacity will be generated in the future. For polyps <6 mm, a clinical consensus is needed to support decision-making and we propose a pragmatic algorithm ( Figure 1 ). This approach is commensurate with the principle of Realistic Medicine and would enable a shift in clinical practice away from a "zero risk" policy for all, which is becoming increasingly difficult to resource, towards one which more appropriately prioritises resource for those patients in the highest risk groups and who have the most to gain from interventions -an approach which should deliver better and more appropriate clinical care for all patients [15] . We thank Campbell MacLeod, surgical research fellow NHS Highland, for drafting and producing the final manuscript. We declare no conflicts of interest related to this article. Data sharing is not applicable to this article as no new data were created or analysed in this study. Systematic review: Distribution of advanced neoplasia according to polyp size at screening colonoscopy Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths Post-colonoscopy complications: a systematic review, time trends, and meta-analysis of population-based studies Clinical Guide for the Management of Patients Requiring Endoscopy during the Coronavirus Pandemic An Update to Information and Guidance for Endoscopy Services in the COVID-19 Pandemic | The British Society of Gastroenterology NHS Diagnostic Waiting Times and Activity Data NHS England and NHS Improvement 2 NHS Diagnostic Waiting Times and Activity Data Clinical Guidance on the Use of Faecal Immunochemical Testing (FIT) in the Prioritisation of Patients with Colorectal Symptoms Colon capsule endoscopy versus CT colonography in FIT-positive colorectal cancer screening subjects: a prospective randomised trial -The VICOCA study Faecal haemoglobin and faecal calprotectin as indicators of bowel disease in patients presenting to primary care with bowel symptoms Impact of introducing a faecal immunochemical test (FIT) for haemoglobin into primary care on the outcome of patients with new bowel symptoms: a prospective cohort study Colon capsule endoscopy: an innovative method for detecting colorectal pathology during the COVID-19 pandemic? 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