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January 19th, 2012

Stewardship in medicine: Is it time to stop sending small polyps to the pathologist?

The American Society for Gastrointestinal Endoscopy has stated: “In order for colorectal polyps <5 mm in size to be resected and discarded without pathologic assessment, endoscopic technology (when used with high confidence) used to determine histology of polyps <5 mm in size, when combined with the histopathologic assessment of polyps >5 mm in size, should provide a >90% agreement in assignment of post-polypectomy surveillance intervals when compared to decisions based on pathology assessment of all identified polyps.”*

 How many of us heed this guidance? We do have technologies that in some of our hands exceed the threshold established here for identifying polyp histology >90% of the time (narrow band imaging, confocal microscopy, etc.). But are we teaching, learning, and implementing these technologies to save the patient and payer the substantial pathology charges arising from resecting the many thousands of these diminutive lesions?

 So my questions to you are:

1. Do you ever use real-time histology technology to assess colon polyps?

2. Which one do you use and in what circumstance (small vs. large polyps, all polyps, etc.)?

3. Do you make clinical decisions based on that assessment?

4. If you do not use the technology to make clinical decisions, what accuracy will it take to allow you to “resect and discard” these small polyps?

 * Rex, et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps (Gastrointest Endosc 2011; 73:419).

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Gastroenterology Research: Author M. Brian Fennerty, M.D.

M. Brian Fennerty, MD

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NEJM Journal Watch Gastroenterology

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