Treatment strategy of diminutive colorectal polyp <5 mm in size – Should it be removed and discarded without pathologic assessment? Cold polypectomy techniques for diminutive polyps in the colorectum Toshio Uraoka, 1 Hemchand Ramberan, 2 Takahisa Matsuda, 3 Takahiro Fujii 4 and Naohisa Yahagi 1 1 Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan, 2 Academic Gastroenterology, Erlanger Hospital, Chattanooga, TN, USA, 3 Endoscopy Division, National Cancer Center Hospital; and 4 TF Clinic, Tokyo, Japan Adequate colonoscopic polypectomy is a very important inter- vention for the prevention of colorectal cancer progression during screening and surveillance colonoscopy. Whereas various techniques are used for the removal of diminutive polyps, includ- ing cold biopsy forceps, hot biopsy forceps, hot snare, and cold snare, hot polypectomy techniques with electrocautery have been associated with an increased risk of electrocautery- related complications, including immediate and/or delayed bleeding or perforation. In contrast, recent studies have found a polypectomy technique without electrocautery, so-called cold polypectomy, to be a safer and more efficacious technique. The present article discusses the use of cold polypectomy techniques and describes how cold biopsy forceps polypectomy using jumbo biopsy forceps designed with a greater capacity for removing larger tissue samples, and cold snare polypectomy, are adequate for removing diminutive polyps completely and safely and shorten withdrawal time of the colonoscopy procedure. Key words: cold biopsy forceps polypectomy, cold polypec- tomy, colonoscopy, diminutive polyp INTRODUCTION A DEQUATE COLONOSCOPIC POLYPECTOMY remains as one of the most important interventions during screening and surveillance colonoscopy in the pre- vention of colorectal cancer progression based on the adenoma-carcinoma sequence and hence reduces colorectal cancer mortality rates. 1,2 Since its introduction to practice, appropriate endoscopic resection techniques have generally been chosen based on polyp size and morphology; however, various approaches have been adopted by individual endos- copists. Historically, polyps ≥6 mm have been removed by snare polypectomy as the technique of choice; 3,4 however, this was done almost exclusively with electrocautery, par- ticularly for polyps >10 mm. According to a survey of 285 US gastroenterologists in 2004, various techniques for removal of polyps (≤6 mm) have been used. For polyps measuring 4–6 mm, 19% reported using cold biopsy forceps, 21% hot biopsy forceps, 59% hot snare, and 15% cold snare. 3 More recently, however, studies have found that a cold polypectomy technique for diminutive polyps (≤5 mm) and small polyps (<10 mm) is also safe and efficacious. 5–7 The present review focuses on the utility, safety and efficacy of the cold polypectomy tech- nique for removing diminutive polyps in the colorectum. COMPLICATIONS OF THE HOT POLYPECTOMY TECHNIQUE T HE APPLICATION OF hot polypectomy techniques including hot snare polypectomy (HSP), endoscopic mucosal resection (EMR) and hot biopsy forceps polypec- tomy (HBP) have been associated with an increased risk of electrocautery-related complications such as immediate and/or delayed bleeding and perforation. Specifically, imme- diate bleeding has been associated with the use of cutting current in HSP, whereas the possibility of delayed bleeding accompanies the use of coagulation current. In a question- naire survey of 517 American Society for Gastrointestinal Endoscopy (ASGE) members, 8 47 delayed bleeding (0.38%) and six delayed perforations (0.05%) were reported with 12 367 hot biopsies. In a subanalysis, limiting the use of hot biopsies to the ascending colon, higher rates of delayed bleeding (0.52%) and delayed perforations (0.26%) were Corresponding: Toshio Uraoka, Division of Research and Develop- ment for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan. Email: toshi_urao@yahoo.co.jp Received 12 December 2013; accepted 10 January 2014. Digestive Endoscopy 2014; 26 (Suppl. 2): 98–103 doi: 10.1111/den.12252 98