Small (<10 mm) and diminutive (<6 mm) polyps harbour high-grade dysplasia or cancer in 0.3-5% of cases. The potential to grow and develop advanced histology is low. Traditional guidelines still recommend the removal of all polyps. Visual characterisation with modern endoscopic technology could enable us to leave diminutive hyperplastic polyps in situ and remove but discard small polyps. In expert hands, high-definition white-light endoscopy and virtual chromoendoscopy can reach an accuracy of more than 90% in distinguishing between hyperplastic and adenomatous pathology. For less experienced endoscopists the values are lower and therefore the concept is not yet fit for routine use. Polyps can be removed completely with snares but not with forceps. The cold snaring technique in particular has proved safe and effective for small polyps. With more experience in the future a ‘cut and discard' strategy for small polyps and a ‘do not resect' strategy for diminutive polyps will save money and time to deal with more advanced lesions.

1.
Rubio CA, Höög CM, Broström O, Gustavsson J, Karlsson M, Moritz P, Stig R, Wikman O, Mattsson L, Palli D: Assessing the size of polyp phantoms in tandem colonoscopies. Anticancer Res 2009;29:1539-1545.
2.
Gupta N, Bansal A, Rao D, Early DS, Jonnalagadda S, Wani SB, Edmundowicz SA, Sharma P, Rastogi A: Prevalence of advanced histological features in diminutive and small colon polyps. Gastrointest Endosc 2012;75:1022-1030.
3.
Gschwantler M, Kriwanek S, Langner E, Göritzer B, Schrutka-Kölbl C, Brownstone E, Feichtinger H, Weiss W: High-grade dysplasia and invasive carcinoma in colorectal adenomas: a multivariate analysis of the impact of adenoma and patient characteristics. Eur J Gastroenterol Hepatol 2002;14:183-188.
4.
Hassan C, Pickhardt PJ, Kim DH, Di Giulio E, Zullo A, Laghi A, Repici A, Iafrate F, Osborn J, Annibale B: Systematic review: distribution of advanced neoplasia according to polyp size at screening colonoscopy. Aliment Pharmacol Ther 2010;31:210-217.
5.
Hofstad B, Vatn MH, Andersen SN, Huitfeldt HS, Rognum T, Larsen S, Osnes M: Growth of colorectal polyps: redetection and evaluation of unresected polyps for a period of three years. Gut 1996;39:449-456.
6.
Hisabe T, Tsuda S, Matsui T, Iwashita A: Natural history of small colorectal protuberant adenomas. Dig Endosc 2010;22(suppl 1):S43-S46.
8.
Kudo S, Tamura S, Nakajima T, Yamano H, Kusaka H, Watanabe H: Diagnosis of colorectal tumorous lesions by magnifying endoscopy. Gastrointest Endosc 1996;44:8-14.
9.
Rastogi A: Optical diagnosis of small colorectal polyp histology with high-definition colonoscopy using narrow band imaging. Clin Endosc 2013;46:120-129.
10.
Hewett DG, Kaltenbach T, Sano Y, Tanaka S, Saunders BP, Ponchon T, Soetikno R, Rex DK: Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging. Gastroenterology 2012;143:599-607.
11.
Ignjatovic A, East JE, Suzuki N, Vance M, Guenther T, Saunders BP: Optical diagnosis of small colorectal polyps at routine colonoscopy (Detect InSpect ChAracterise Resect and Discard; DISCARD trial): a prospective cohort study. Lancet Oncol 2009;10:1171-1178.
12.
Paggi S, Rondonotti E, Amato A, Terruzzi V, Imperiali G, Mandelli G, Terreni N, Lenoci N, Spinzi G, Radaelli F: Resect and discard strategy in clinical practice: a prospective cohort study. Endoscopy 2012;44: 899-904.
13.
Ladabaum U, Fioritto A, Mitani A, Desai M, Kim JP, Rex DK, Imperiale T, Gunaratnam N: Real-time optical biopsy of colon polyps with narrow band imaging in community practice does not yet meet key thresholds for clinical decisions. Gastroenterology 2013;144:81-91.
14.
Hassan C, Pickhardt PJ, Rex DK: A resect and discard strategy would improve cost-effectiveness of colorectal cancer screening. Clin Gastroenterol Hepatol 2010;8:865-869.
15.
Hewett DG, Huffman ME, Rex DK: Leaving distal colorectal hyperplastic polyps in place can be achieved with high accuracy by using narrow-band imaging: an observational study. Gastrointest Endosc 2012;76:374-380.
17.
Häfner M, Liedlgruber M, Uhl A, Vécsei A, Wrba F: Delaunay triangulation-based pit density estimation for the classification of polyps in high-magnification chromo-colonoscopy. Comput Methods Programs Biomed 2012;107:565-581.
18.
Efthymiou M, Taylor AC, Desmond PV, Allen PB, Chen RY: Biopsy forceps is inadequate for the resection of diminutive polyps. Endoscopy 2011;43:312-316.
19.
Metz AJ, Moss A, McLeod D, Tran K, Godfrey C, Chandra A, Bourke MJ: 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;77:484-490.
20.
Tappero G, Gaia E, De Giuli P, Martini S, Gubetta L, Emanuelli G: Cold snare excision of small colorectal polyps. Gastrointest Endosc 1992;38:310-313.
21.
Repici A, Hassan C, Vitetta E, Ferrara E, Manes G, Gullotti G, Princiotta A, Dulbecco P, Gaffuri N, Bettoni E, Pagano N, Rando G, Strangio G, Carlino A, Romeo F, de Paula Pessoa Ferreira D, Zullo A, Ridola L, Malesci A: Safety of cold polypectomy for <10 mm polyps at colonoscopy: a prospective multicenter study. Endoscopy 2012;44:27-31.
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