Too Much Forceps Removal of Small Polyps, but It Could Be Modified

Anecdotally, many colonoscopists still use forceps to remove small and diminutive colorectal polyps that are more effectively and efficiently removed by snare polypectomy.

In 2 U.S. health centers over a 2-year period, the prevalence of forceps polypectomy was noted, and an intervention was employed. During a faculty meeting of gastroenterologists from both health systems, education on cold snare polypectomy was provided, a prespecified metric of ≥75% of nondiminutive polyps being resected with a snare was presented, and questions were answered. The faculty received one-time feedback on the group’s progress toward the metric, which had been tied to a financial incentive of approximately $1000 per gastroenterologist. 

Forty-two attending GI doctors were involved, with a median of 184 colonoscopies performed per doctor. Of 25,534 polypectomies, forceps were used to remove 51.9% of polyps 1 to 4 mm in size and 23.7% of those 5 to 9 mm in size. Removal with forceps was considered inappropriate for polyps ≥5 mm so that 8.5% of all polypectomies were deemed inappropriate forceps removal, of which 86.5% were for polyps 5 to 6 mm in size. Of the polyps measuring exactly 5 mm, 52.2% were removed with forceps. 

Inappropriate forceps polypectomy as defined in the study decreased from 11.4% to 5.3% after the intervention. The proportion of polyps inappropriately removed by forceps ranged from 0% to 29.2% among endoscopists.

If removal of polyps using forceps was confined to polyps ≤2 mm in size, as recommend by the U.S. Multi-Society Task Force on Colorectal Cancer, then the rate of inappropriate forceps removal was 50% before the intervention and declined to 43% after the intervention.