Polypectomy

A polypectomy is a minimally invasive medical procedure used to remove polyps, which are abnormal growths of tissue that protrude from the mucous membrane of various organs, most commonly the colon, uterus, or nasal passages, in order to prevent potential progression to cancer.^[1] These growths are often benign but can be precancerous, and their removal allows for pathological examination to assess malignancy risk.^[2] The procedure is typically performed endoscopically, using specialized instruments inserted through natural body openings, making it a safer alternative to open surgery for most cases.^[3] In the context of colorectal health, polypectomy is a cornerstone of preventive care, often conducted during a routine colonoscopy where a flexible tube equipped with a camera (colonoscope) is inserted through the rectum to visualize and excise polyps.^[2] Techniques vary by polyp size and location: small polyps (under 5 mm) are snared with a wire loop or grasped with biopsy forceps, while larger ones may require endoscopic mucosal resection (EMR), involving injection of fluid to lift the polyp before cutting, or even advanced methods like endoscopic submucosal dissection (ESD) for complex lesions.^[1] Electrocautery is commonly applied to seal blood vessels and minimize bleeding during removal.^[3] This intervention has significantly lowered colorectal cancer incidence and mortality, as removing adenomas—the most common precancerous polyps—interrupts their progression to malignancy.^[2] While generally safe, polypectomy carries risks including bleeding (occurring in about 1.5 per 1,000 procedures), perforation of the colon wall (around 0.3 per 1,000), and infection, particularly in patients on blood thinners or with larger polyps.^[2] Recovery is typically rapid, with patients resuming normal activities within days, though follow-up surveillance colonoscopies are recommended based on polyp characteristics—such as number, size, and histology—to monitor for recurrence.^[3] For uterine or nasal polyps, similar endoscopic approaches apply, tailored to the site, emphasizing polypectomy's versatility in gynecological and otolaryngological settings.^[1]

Overview

Definition and Types of Polyps

A polyp is an abnormal growth of tissue that projects from the mucous membrane, typically arising from the epithelial lining of various organs. These growths can vary in size, shape, and composition, and while many are benign, some harbor the potential to develop into malignancies if left untreated. Polypectomy refers to the surgical or endoscopic removal of such polyps, a procedure aimed at excising the growth while preserving the integrity of the surrounding tissue.^[4][5] Polyps are broadly classified based on their histological features and malignant potential. Non-neoplastic polyps, such as hyperplastic polyps, are generally benign and result from localized overgrowth without dysplastic changes, whereas neoplastic polyps, including adenomatous and serrated types, exhibit cellular atypia and carry a risk of progression to cancer through the adenoma-carcinoma sequence or serrated neoplasia pathway. Additionally, polyps are categorized by morphology into sessile (broad-based and flat, attaching directly to the mucosal surface) and pedunculated (stalked, with a narrow base connecting to a pedicle), which influences detection and removal strategies.^[6][4][5] Polyps commonly occur in the gastrointestinal tract, particularly the colon and stomach, but can also develop in the uterus (endometrial polyps), nasal passages (nasal polyps), urinary bladder, and even on the skin as cutaneous manifestations. In the gastrointestinal context, they often form on the mucosal surface exposed to mechanical or chemical irritation.^[7][8] The basic pathophysiology of polyps involves dysregulated epithelial proliferation, where cells in the mucosal lining undergo excessive growth due to genetic mutations or environmental triggers. Factors such as chronic inflammation, as seen in inflammatory bowel disease, or inherited genetic predispositions, like those in familial adenomatous polyposis, promote this proliferation and can lead to polyp formation. Removal of these polyps through polypectomy plays a key role in preventing potential malignant transformation.^[9][8]

Medical Importance

Polypectomy holds significant medical importance primarily due to the high prevalence of colorectal polyps, which are the most common type requiring removal. In adults aged 50 years and older, colonoscopy detects adenomatous polyps in approximately 25.9% of cases (95% CI, 23.5–28.4), with overall polyp prevalence ranging from 25% to 47% depending on population and screening methods. ^{[10] [11]} Risk factors for developing colorectal polyps include advancing age, diets high in red and processed meats and low in fiber, cigarette smoking, obesity, and heavy alcohol use, all of which elevate susceptibility in at-risk populations. ^{[5] [12]} Colorectal polyps account for the vast majority of polypectomies performed globally, reflecting their widespread occurrence and the preventive focus of screening programs. The health impacts of polyps underscore the critical role of polypectomy in cancer prevention, as adenomatous polyps are key precursors to colorectal cancer via the adenoma-carcinoma sequence, which accounts for approximately 75% of all colorectal cancer cases. ^[13] Without intervention, only about 10% of conventional adenomas progress to malignancy, but their removal through polypectomy substantially mitigates this risk, reducing colorectal cancer incidence by 67% and mortality by 53% to 90% in screened populations. ^{[14] [15]} This preventive effect contributes to broader public health benefits, particularly as colorectal cancer remains a leading cause of cancer-related deaths worldwide, with over 1.9 million new cases reported annually by the World Health Organization as of 2022. ^[16] Even non-cancerous polyps carry clinical significance by causing symptomatic complications that necessitate polypectomy. In the colorectum, hyperplastic or inflammatory polyps can lead to rectal bleeding, mucus discharge, abdominal pain, or bowel obstruction when large, impacting quality of life and prompting intervention. ^{[17] [6]} Similarly, uterine (endometrial) polyps, which are typically benign, often present with abnormal uterine bleeding, irregular menstrual cycles, or postmenopausal spotting, and are found in 15% to 25% of women experiencing infertility, potentially by interfering with embryo implantation. ^{[18] [19]}

Indications

Detection and Diagnosis

The detection and diagnosis of polyps, which are growths that may necessitate polypectomy, primarily rely on endoscopic visualization as the cornerstone method across various anatomical sites. For gastrointestinal polyps, particularly in the colon and rectum, colonoscopy serves as the gold standard diagnostic tool, allowing direct visualization of the mucosal surface and detection of nearly all lesions greater than 1 cm in size with a sensitivity exceeding 95%.00110-9/fulltext) In the uterus, hysteroscopy provides definitive diagnosis by enabling direct inspection of the endometrial cavity, often combined with biopsy for confirmation, and is recommended as the preferred method for symptomatic patients or those with abnormal uterine bleeding.^[20] For bladder polyps, cystoscopy offers high-resolution imaging of the urothelium through a flexible or rigid scope inserted via the urethra, facilitating the identification of suspicious lesions and immediate biopsy if needed.^[21] Nasal endoscopy, using a thin, flexible fiberoptic scope, is the primary diagnostic approach for sinonasal polyps, allowing assessment of polyp extent and associated inflammation in patients with chronic rhinosinusitis.^[22] When direct endoscopy is contraindicated or not immediately feasible—such as in patients with comorbidities precluding sedation—noninvasive imaging modalities serve as alternatives for initial polyp screening. Computed tomography (CT) colonography, also known as virtual colonoscopy, demonstrates comparable sensitivity to optical colonoscopy for detecting colorectal polyps larger than 6 mm (around 90% for advanced adenomas) and is particularly useful for incomplete colonoscopies or patient preference.^[23] Transvaginal ultrasound is a first-line imaging option for uterine polyps, offering high sensitivity (up to 90%) for lesions greater than 1 cm through sonographic evaluation of endometrial thickness and morphology. For bladder evaluation, pelvic ultrasound can detect larger polyps or masses but lacks the precision of cystoscopy for smaller lesions. Magnetic resonance imaging (MRI) may be employed in select cases for sinonasal or pelvic polyps to delineate extent and involvement of adjacent structures when endoscopy is limited.13846-6/fulltext) Once a polyp is identified endoscopically, biopsy sampling is essential to determine its histological nature and guide the decision for polypectomy. Tissue is obtained via forceps through the endoscope, and pathological examination assesses for features such as adenomatous changes, villous architecture, or invasive components. Dysplasia grading—categorized as low-grade (mild to moderate architectural and cytologic atypia) or high-grade (severe atypia approaching carcinoma)—is a critical component of this analysis, influencing risk stratification and urgency of removal.^[24] Histological confirmation helps distinguish benign hyperplastic polyps from precancerous adenomas, with high-grade dysplasia warranting prompt intervention.^[25] Screening guidelines emphasize early detection to prevent progression to malignancy, particularly for colorectal polyps in average-risk individuals. The U.S. Preventive Services Task Force (USPSTF) recommends initiating colorectal cancer screening, which includes colonoscopy for polyp detection, at age 45 for those at average risk, with intervals of 10 years for normal findings.^[26] For other sites, such as the uterus or bladder, screening is typically symptom-driven rather than routine, with hysteroscopy or cystoscopy reserved for patients with risk factors like postmenopausal bleeding or hematuria. Nasal polyp evaluation follows guidelines from organizations like the American Academy of Otolaryngology, recommending endoscopy for persistent sinonasal symptoms.^[27]

Preventive and Therapeutic Roles

Polypectomy plays a crucial preventive role in reducing the incidence of colorectal cancer by removing precancerous adenomas, which are known precursors to malignancy. Landmark evidence from the National Polyp Study demonstrated that colonoscopic polypectomy resulted in a 76% to 90% reduction in expected colorectal cancer cases compared to reference populations, with only five early-stage cancers observed over 8,401 person-years of follow-up among 1,418 patients.^[28] This intervention is particularly effective when integrated with surveillance colonoscopy, where intervals are tailored to polyp characteristics: for example, patients with 3 to 4 tubular adenomas smaller than 1 cm typically undergo follow-up in 3 to 5 years, while those with advanced features like villous histology or larger polyps require shorter intervals of 1 to 3 years to monitor for recurrence and further neoplastic progression.^[29] In high-risk populations, such as individuals with Lynch syndrome, polypectomy's preventive impact is amplified through more intensive surveillance, with guidelines recommending colonoscopy every 1 to 2 years starting at ages 20 to 25 or 2 to 5 years before the earliest family diagnosis of colorectal cancer, enabling early detection and removal of polyps to mitigate the lifetime cancer risk exceeding 50%. Updated 2025 consensus from multi-society task forces continues to emphasize these risk-stratified approaches, prioritizing complete excision of high-risk polyps—defined by villous architecture, size greater than 1 cm, or high-grade dysplasia—to prevent malignant transformation.^[30] Therapeutically, polypectomy addresses symptomatic manifestations across various sites, alleviating complications that impair quality of life or function. In the nasal cavity, removal is indicated for polyps causing recurrent epistaxis or obstruction unresponsive to medical therapy, thereby reducing bleeding episodes and restoring airflow.^[31] For uterine polyps, which can distort the endometrial cavity and interfere with implantation, polypectomy is recommended in cases of infertility or recurrent miscarriage, with studies showing improved pregnancy rates post-removal, such as a rise from 28% to 63% in assisted reproduction cycles.^[32] Complete excision is essential for polyps exhibiting high-risk histologic features, like villous components in colorectal cases, to eliminate ongoing symptoms such as bleeding or obstruction while preventing progression to invasive disease. Despite its benefits, polypectomy has relative contraindications that may necessitate delaying the procedure to minimize risks. Active infections, such as acute diverticulitis or peritonitis, can increase the likelihood of procedural complications and are typically addressed prior to intervention.^[33] Similarly, uncorrected coagulopathy—evidenced by elevated INR or thrombocytopenia—poses a significant bleeding hazard during polypectomy, requiring optimization of hemostatic parameters according to antithrombotic management guidelines before proceeding.^[34]

Procedures

Endoscopic Techniques

Endoscopic polypectomy represents the primary minimally invasive approach for removing polyps from various body cavities, leveraging flexible or rigid endoscopes to visualize and excise lesions while minimizing tissue trauma.^[35] These techniques are most commonly applied in the gastrointestinal tract, uterus, and nasal sinuses, with adaptations based on polyp location, size, and morphology.^[36] The procedure typically involves sedation, polyp identification, targeted resection, and specimen retrieval, prioritizing complete removal to reduce recurrence risk.^[37] In colonoscopic polypectomy, the most prevalent endoscopic method, small polyps (≤10 mm) are often addressed using snare polypectomy. Cold snare polypectomy, without electrocautery, is recommended for diminutive (≤5 mm) and small (6-9 mm) polyps, involving encirclement with a snare to include a 1-2 mm margin of normal tissue followed by mechanical transection.^[35] For slightly larger pedunculated or sessile polyps (10-19 mm), hot snare polypectomy employs electrosurgical current for cutting and coagulation, reducing bleeding risk; submucosal injection of saline or other solutions may precede this to lift the lesion and prevent deep thermal injury.^[35] Larger sessile polyps (≥20 mm) require endoscopic mucosal resection (EMR), where submucosal injection creates a cushion, followed by snare excision; en bloc removal is ideal for lesions <20 mm, while piecemeal resection in multiple pieces is standard for those >20-25 mm, often concluding with snare-tip soft coagulation of margins to ablate residual tissue.^[35] For complex lesions, such as large sessile polyps with suspected limited submucosal invasion, endoscopic submucosal dissection (ESD) may be considered. ESD involves a circumferential incision around the lesion followed by submucosal dissection using specialized electrosurgical knives to achieve en bloc resection, enabling precise histopathological assessment and higher R0 resection rates compared to EMR, though it is more time-consuming and technically demanding.^[35] The step-by-step process for colonoscopic polypectomy begins with patient sedation, typically moderate, to ensure comfort.^[36] A colonoscope is advanced to visualize the polyp, which is assessed for size, shape, and vascularity using high-definition imaging.^[35] For snare techniques, the polyp is grasped or encircled, cut, and retrieved using forceps; in EMR, injection precedes snaring to elevate the lesion.^[35] Post-resection, the site is inspected for hemostasis, with clips applied prophylactically in high-risk areas like the right colon.^[35] Essential equipment includes video colonoscopes, wire snares (cold or hot), injection needles, biopsy forceps, and electrosurgical units with blended current settings.^[36] Hysteroscopic polypectomy targets uterine polyps using a hysteroscope inserted transcervically under direct visualization.^[20] The procedure involves distending the uterine cavity with saline or glycine, followed by loop resection with a bipolar resectoscope wire loop for cutting and coagulation, or mechanical removal via grasping forceps or scissors for smaller polyps.^[20] Bipolar energy is preferred over monopolar to minimize fluid overload and thermal risks.^[38] For large polyps, slicing into fragments allows piecemeal extraction, with newer tissue removal systems enabling simultaneous morcellation and aspiration.^[20] Equipment comprises rigid or flexible hysteroscopes, resectoscopes, and fluid management systems.^[38] Endoscopic nasal polypectomy employs a nasal endoscope to access and remove sinonasal polyps, often under local or general anesthesia.^[39] Techniques include microdebrider-assisted resection, where a powered rotating blade shaves polyps precisely, or snare polypectomy using a wire loop for avulsion, particularly for pedunculated lesions.^[39] The endoscope guides visualization through the nostrils, with polyps excised and suctioned; electrosurgical coagulation may control bleeding.^[40] Key equipment includes rigid nasal endoscopes (0-30° angles), microdebriders, and snares.^[39] Advancements in endoscopic techniques include underwater EMR (UEMR) for colorectal polyps, where the colonic lumen is filled with water to float the mucosa, obviating submucosal injection and facilitating en bloc resection of 10-20 mm lesions with comparable safety to conventional EMR.^[41] By 2025, UEMR has demonstrated superior R0 resection rates for medium-sized sessile polyps, reducing recurrence through improved lifting and cutting depth.^[42]

Surgical and Other Methods

Surgical methods for polypectomy are employed when endoscopic approaches are infeasible, such as for large, sessile, or multiple colorectal polyps that pose risks of incomplete removal or perforation during scoping. Open or laparoscopic surgery, including segmental colectomy, is indicated for polyps exceeding 2 cm in size, those with broad bases, inaccessible locations, or suspected malignant transformation based on biopsy findings.^[43] In laparoscopic colectomy, small abdominal incisions allow insertion of trocars for a camera and instruments to mobilize the colon, ligate vessels, and resect the affected segment with lymph node sampling, following an oncologic no-touch technique to minimize spread.^[43] This approach offers advantages over open surgery, including reduced postoperative pain, faster bowel recovery, and shorter hospital stays (mean 8 days), though operative times are longer and conversion to open occurs in about 11% of cases.^[43] Morbidity is low at 11%, with no procedure-related mortality in most series.^[43] Other non-endoscopic methods include cryotherapy and laser ablation, applied to polyps in accessible sites like the nasal cavity. Cryotherapy for nasal polyps involves spray application of extreme cold during functional endoscopic sinus surgery to promote healing and reduce recurrence, enhancing outcomes when combined with standard resection.^[44] Incidental polypectomy may occur during laparotomy for unrelated abdominal conditions, where polyps are encountered and resected opportunistically to prevent future complications. Surgical polypectomy is reserved for scenarios like prior failed endoscopy, high suspicion of submucosal invasion (e.g., non-lifting sign or NICE type 3 pattern), or anatomical challenges such as polyps behind folds.^[36][45] The historical shift from open to minimally invasive techniques has markedly reduced surgical reliance, with colorectal surgery for benign polyps declining from 4.1 to 3.0 per 1000 cases between 2014 and 2024, now comprising less than 5% of interventions due to advanced endoscopic alternatives.^[46]

Risks and Complications

Immediate Adverse Events

Bleeding is the most common immediate adverse event following polypectomy, occurring in approximately 0.3% to 6.1% of colonoscopic procedures, with rates up to 6% for large or complex polyps.^[47] Risk factors include polyp size greater than 10 mm, location in the right colon, and concurrent use of antiplatelet agents such as aspirin or clopidogrel.^[48] In gastric polypectomy, bleeding rates are generally lower, around 0.65%, though immediate hemorrhage can still require endoscopic intervention.^[49] Perforation, a tear in the bowel wall, affects 0.05% to 0.3% of colonoscopic polypectomies, with higher rates (up to 0.8 per 1,000) during therapeutic interventions like endoscopic mucosal resection (EMR).^[48] Symptoms typically include acute abdominal pain, distension, and fever, often detected intra-procedurally or shortly thereafter via imaging or clinical signs.^[50] For gastric procedures, perforation incidence is similarly low at about 0.05%, but risks increase with snare techniques or larger lesions.^[49] Other immediate adverse events are less frequent but noteworthy. Infections are rare, with transient bacteremia occurring in up to 2.2% of cases, though clinically significant infections develop in fewer than 0.1%.^[51] Sedation-related reactions, such as hypoxemia or cardiovascular instability, arise in 1-2% of sedated colonoscopies, particularly with propofol anesthesia, and are more common in elderly patients or those with comorbidities.^[50] Postpolypectomy syndrome, characterized by abdominal pain and fever due to transmural thermal injury without perforation, has an incidence of 0.07% to 1%, typically resolving with conservative measures but mimicking perforation clinically.^[52] Incidence rates vary by anatomical site, with colonic procedures generally showing higher bleeding risks compared to gastric ones, per meta-analyses through 2023.^[53]

Management and Prevention

Management of polypectomy complications requires prompt recognition and intervention to minimize adverse outcomes. Postpolypectomy bleeding, the most common issue, is typically addressed endoscopically through techniques such as hemoclips or band ligation to achieve hemostasis, often resolving the event without further intervention.^[54] Perforation, though rarer, demands immediate broad-spectrum antibiotics and close monitoring; conservative management suffices for small, contained perforations, while surgical repair is indicated for larger or free perforations.^[55] Postpolypectomy coagulation syndrome, characterized by abdominal pain and fever due to transmural thermal injury, is managed supportively with bowel rest, intravenous fluids, and antibiotics, alongside observation to rule out perforation.^[56] Prevention strategies emphasize patient optimization and procedural precision. Adequate bowel preparation is essential to enhance visualization and reduce procedural risks, with studies showing improved safety profiles in well-prepped colons.^[57] For patients on antithrombotics, guidelines recommend holding agents peri-procedurally and resuming them post-operatively based on thrombotic risk, avoiding unnecessary bridging in low-risk cases to prevent bleeding.^[34] Technique selection plays a key role; cold snare polypectomy is preferred for small, low-risk polyps (<10 mm) due to its lower bleeding and perforation rates compared to hot snare methods.^[58] Patient selection involves assessing comorbidities and polyp characteristics to defer high-risk cases for alternative approaches when feasible.^[54] Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) highlight tailored management for high-risk patients, such as using low-molecular-weight heparin bridging in those with elevated thrombotic risk during anticoagulant interruption.^[34] Additionally, prophylactic clip closure of mucosal defects is recommended following endoscopic mucosal resection (EMR) of large lesions, particularly in the right colon, to reduce delayed bleeding and perforation risks.^[37] Overall, most polypectomy complications resolve without long-term sequelae when managed appropriately, with procedure-related mortality remaining below 0.1%.^[59]

Recovery and Follow-up

Post-Procedure Care

Following polypectomy, most procedures, particularly endoscopic ones for colorectal polyps, are conducted on an outpatient basis, allowing patients to return home the same day after a brief recovery period. Patients are typically monitored for 1 to 2 hours post-procedure to ensure recovery from sedation and to observe for immediate complications such as bleeding or perforation.^[60][61] A responsible adult should accompany the patient home, as driving or operating machinery is prohibited for at least 24 hours due to the effects of anesthesia.^[1] Dietary guidelines emphasize a gradual return to normal eating to minimize gastrointestinal irritation. Immediately after the procedure, patients may begin with clear liquids or soft, bland foods such as broth, applesauce, white toast, or plain yogurt to ease digestion. A normal diet can usually be resumed within 24 hours, though more restrictive instructions may apply if multiple or large polyps were removed. To reduce the risk of bleeding, nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen should be avoided for 7 to 14 days; acetaminophen is recommended for pain relief instead.^[62][63] Patients must vigilantly monitor for symptoms indicating potential complications during the initial recovery phase. Light bleeding or spotting in the stool is common and typically resolves without intervention, but any substantial rectal bleeding—exceeding a few tablespoons (approximately 1/2 cup)—warrants immediate medical attention. Other red flags include severe abdominal pain unrelieved by over-the-counter remedies, fever above 100.4°F (38°C), chills, dizziness, or persistent nausea, as these may signal issues like post-polypectomy coagulation syndrome or infection. Prompt reporting allows for timely management, such as endoscopic reevaluation if needed.^[64][1][65] The excised polyp tissue is routinely submitted for histopathological analysis to assess for dysplasia or malignancy, which guides subsequent care. Results are generally available within 1 to 2 weeks, during which patients should follow up with their healthcare provider; benign findings often require no immediate action beyond routine monitoring, while malignant results may necessitate additional interventions like further resection or oncology consultation.^[64][1]

Surveillance Guidelines

Surveillance after polypectomy aims to detect recurrent or metachronous polyps early, thereby reducing the risk of progression to colorectal cancer (CRC) or other malignancies. Guidelines from the U.S. Multi-Society Task Force (USMSTF) on Colorectal Cancer stratify follow-up intervals based on polyp characteristics and patient risk factors, primarily through repeat colonoscopy for colorectal cases. For low-risk findings, such as 1–2 tubular adenomas less than 10 mm, surveillance colonoscopy is recommended at 7–10 years. In contrast, high-risk features like more than 10 adenomas, adenomas 10 mm or larger, those with villous histology, high-grade dysplasia, or sessile serrated polyps 10 mm or larger warrant shorter intervals of 3 years or less, with surveillance at 1 year for over 10 adenomas. Hyperplastic polyps smaller than 10 mm in the rectum or sigmoid typically require no intensified surveillance beyond standard CRC screening at 10 years.^[66] For polypectomies in other sites, such as the uterus or nasal passages, surveillance is tailored to recurrence risk, symptoms, and pathology; it is typically individualized without standardized routine intervals like those for colorectal polyps. For example, in high-risk uterine cases (e.g., patients on tamoxifen therapy), follow-up may involve symptom monitoring and periodic evaluation with transvaginal ultrasound or hysteroscopy if recurrence is suspected, rather than annual procedures. For nasal polyps, post-procedure care often includes topical corticosteroids and regular otolaryngologic follow-up to monitor for symptom recurrence.^[38][1] As of 2025, updates incorporate artificial intelligence (AI)-assisted endoscopy to enhance polyp detection during surveillance colonoscopies, increasing adenoma detection rates by approximately 8% without clear evidence yet of further CRC prevention beyond standard methods. Personalization based on genetics, such as APC gene mutations in familial adenomatous polyposis (FAP), recommends more frequent surveillance—every 1–2 years via colonoscopy and polypectomy—to manage hundreds of polyps and near-100% lifetime CRC risk if untreated.^[67][68][69] Post-polypectomy surveillance has demonstrated effectiveness in reducing CRC incidence by 76–90% and mortality by 69–92% compared to no surveillance, with recent data showing a 77% relative risk reduction in CRC development. Integration of lifestyle advice, including a high-fiber diet, regular exercise, and smoking cessation, further supports prevention by lowering metachronous advanced neoplasia risk by up to 50% in adherent patients.^[70][71][72]

History and Advances

Early Developments

The earliest recorded references to polyp removal date back to ancient times, with Hippocrates (c. 460–370 BCE) providing the first detailed descriptions of nasal polyps, likening them to marine organisms and outlining surgical techniques for their excision, such as the "lopping method" using a heated iron or the "sponge method" involving ligation and traction.^[73] These approaches represented rudimentary surgical excisions, often performed blindly through the nasal passages, and laid the groundwork for understanding polyps as benign growths amenable to removal, though limited to accessible sites like the nose and rectum.^[74] Early Hindu texts from around 600 BCE also alluded to similar nasal polyp treatments, indicating a cross-cultural recognition of these lesions predating Greek contributions.^[75] In the pre-endoscopic era, gastrointestinal (GI) polyps, particularly in the colon, were managed through invasive open surgical procedures such as colotomy—direct incision into the colon—or more extensive resections like partial colectomy, which were necessitated by the inability to visualize or access lesions endoscopically.^[76] These operations, common from the 19th century onward, carried high morbidity rates due to risks of infection, bleeding, perforation, and prolonged recovery, often exceeding 20–30% complication rates in historical reports, as surgical access required laparotomy and lacked precise localization tools like barium enemas, which were unreliable for small or proximal polyps.^[77] Such interventions were typically reserved for symptomatic or large polyps suspected of malignancy, underscoring the limitations of non-endoscopic diagnostics and the significant perioperative hazards.^[78] The 19th century marked a pivotal shift with the advent of endoscopy, beginning with Philipp Bozzini's Lichtleiter in 1806, an illuminated tube for rectal and urethral visualization that enabled early forceps-based polyp removals in accessible areas.^[78] This evolved into more advanced instruments, such as Maximilian Nitze's cystoscope introduced in 1879, which incorporated electric illumination and lenses for bladder examination, facilitating the first targeted polypectomies in the urinary tract using biopsy forceps to grasp and excise visible lesions under direct vision.^[79] By the late 19th century, rigid sigmoidoscopes allowed similar forceps techniques for rectal polyps, reducing reliance on blind surgery but still confined to distal GI sites due to instrument rigidity and limited lighting.^[78] A key milestone in the mid-20th century occurred in 1969 when Hiromi Shinya, collaborating with William Wolff, developed the electrosurgical snare—a wire loop delivered via colonoscope that used electrocautery to safely resect colonic polyps endoscopically for the first time, transforming polypectomy from a high-risk surgical procedure to a minimally invasive outpatient intervention.^[80] This innovation, applied in over 1,600 procedures by 1972, dramatically lowered morbidity compared to open methods and established the foundation for routine colorectal screening.^[81]

Modern Innovations

The widespread adoption of colonoscopy in the 1980s and 1990s revolutionized colorectal screening and enabled routine polypectomy, significantly expanding access to preventive interventions for large lesions. During this period, endoscopic mucosal resection (EMR) emerged as a key innovation, introduced in the 1990s as an extension of standard snare polypectomy techniques specifically for resecting larger, sessile polyps that were previously challenging to remove endoscopically without surgery. EMR involves submucosal injection to elevate the lesion, followed by snare resection, allowing for en bloc or piecemeal removal of polyps up to 20 mm or larger, with high success rates and reduced need for invasive procedures.^[82] In the 2000s, endoscopic submucosal dissection (ESD), originating in Japan, advanced the field further by enabling precise en bloc resection of larger colorectal lesions, including early cancers confined to the mucosa or superficial submucosa.^[83] Developed initially for gastric neoplasms in the late 1990s and adapted for colorectal use by the early 2000s, ESD uses specialized knives for circumferential incision and submucosal dissection, achieving R0 resection rates over 90% in expert centers and minimizing recurrence compared to piecemeal EMR.^[84] This technique, now endorsed in Japanese guidelines for colorectal ESD, has spread globally, particularly for lesions >20 mm or those with fibrosis.^[83] The integration of artificial intelligence (AI) for real-time polyp detection marked a major leap in the 2020s, with the U.S. Food and Drug Administration (FDA) approving the first computer-aided detection systems, such as GI Genius in 2021, to assist endoscopists during colonoscopy.^[85] These AI modules, like those from Medtronic and Olympus, analyze video feeds to highlight potential polyps, improving adenoma detection rates by 20-50% and reducing miss rates, as demonstrated in multicenter trials.^[86] By 2024, cloud-based AI systems like Olympus's CADDIE received FDA clearance, enhancing efficiency in identifying advanced adenomas during polypectomy procedures. As of 2025, robotic endoscopy platforms are emerging to improve precision and safety in complex polypectomies, with innovations like soft robotic add-ons for existing colonoscopes enabling better maneuverability and reduced procedural risks.^[87] Systems such as MicroSteer and EndoQuest Robotics facilitate targeted resection of difficult polyps, achieving high success rates in early clinical trials without altering standard workflows.^[88] Non-invasive pre-polypectomy markers, including multi-target stool DNA tests like Cologuard, now complement endoscopy by identifying high-risk individuals for prioritized intervention, with the Cologuard Plus test demonstrating 95% sensitivity for colorectal cancer and 43% for advanced precancerous lesions, as per its 2024 FDA approval.^[89] Hybrid techniques, combining elements of EMR and ESD or incorporating cold snare with traction devices, have further reduced complications like bleeding and perforation to under 5% for large polyps. These advancements have established polypectomy as a cornerstone of colorectal cancer prevention, with long-term studies indicating it averts approximately 50% of cases by removing precancerous adenomas.^[90] Global standardization efforts, led by organizations like the American Society for Gastrointestinal Endoscopy (ASGE) through consensus guidelines on techniques and surveillance, ensure consistent quality and optimal outcomes across practices.^[36]