Fellow Experience Level Correlates With Adherence to Polypectomy Guidelines

colon polyp
polyp, polypectomy, colonoscopy, colon polyp
The investigators evaluated whether the participation of fellows at different stages of training affects the selection of polypectomy strategy.

Gastroenterology fellows’ adherence to guideline-supported strategies for polypectomy was found to correlate with experience level, suggesting that the choice of polypectomy technique is related to skill level, according to findings from a retrospective review presented at the 2020 American College of Gastroenterology (ACG) Annual Scientific Meeting.

Investigators from the University of Missouri reviewed patient records from all individuals who underwent a screening colonoscopy at their institution between January 2018 and June 2019. They identified 895 colonoscopies that were subsequently included in the analysis.

The study authors specifically sought to assess adherence to the US Multi-Society Task Force on Colorectal Cancer’s (USMSTF’s) guidelines for polypectomy and evaluate whether the participation of fellows at various stages of training affects the choice of polypectomy technique. During the study period, 950 polyps were resected, and nearly half (43.8%) of these resections were executed by a fellow.

Current USMSTF guidance recommends cold snare polypectomy for lesions smaller than 1 cm, and cold forceps resection for lesions less than or equal to 2 mm in size when cold snare polypectomy is not feasible. Despite this guidance, 96.3% of polyps less than or equal to 2 mm in size were resected with cold biopsy forceps during the study period. Cold biopsy forceps were also used to resect 39.7% of polyps 3 mm to 5 mm in size. The use of cold biopsy forceps in these instances correlated with a fellow’s presence at the procedure, the study authors observed.

The selection of removal strategy appeared to be influenced by skill level, with Nehme et al discovering that “more senior fellows [were] significantly more likely” to use cold snare polypectomy to resect polyps 3 mm to 9 mm in size, as recommended (P =.004). Specifically, 66.7% of third-year fellows used cold snare polypectomy vs 44.3% and 42.6% of second- and first-year fellows, respectively.

Notably, third-year fellows were also less likely to subvert USMSTF guidance by using cold forcep or hot snare polypectomy over cold snare polypectomy when resecting polyps in the 3 mm to 5 mm range. The rates for cold forcep polypectomy use among third-year, second-year, and first-year fellows were 32.1%, 49.4%, and 48.5%, respectively.

A similar trend was seen with hot snare polypectomy, which, like cold forcep polypectomy, is not recommended for the resection of lesions of this size. Third-year fellows were the least likely to use hot snare polypectomy (1.3%), followed by second-year fellows (6.3%), and first-year fellows (8.8%).

Overall, cold forcep polypectomy was found to be used “more commonly in the presence of fellows” to remove polpys 3 mm to 5 mm in size vs when attending physicians facilitated the procedure alone (42.9% vs 36.7%; P <.05). Cold snare polypectomy also tended to be used in accordance with USMSTF recommendation when a fellow was not present (53.2% vs 41.8%).

Interestingly, the investigators noted “significantly” lower use of hot snare polypectomy in the resection of 6 mm to 9 mm polyps when fellows participated (P <.001).

“Adherence to recent evidence on appropriate polypectomy techniques remains suboptimal in clinical practice regardless of fellow participation,” the study authors stated. “Selection of polypectomy technique by GI fellows appears to be related to endoscopy skill level given [the] more frequent use of cold forceps polypectomy and less frequent use of hot snare polypectomy compared [with] GI attendings. Standardized training with adherence to USMSTF recommendations should be emphasized during fellowship training for complete and safe removal of colorectal lesions in order to optimize prevention of colorectal cancer in the future,” they concluded.


Nehme F, Elkafrawy A, Zamir H, et al. Impact of GI fellow participation on polyp resection technique during screening. Presented at: American College of Gastroenterology Annual Scientific Meeting; October 26-28, 2020. Abstract S0297.