Follow-up of small & diminutive colonic polyps - how to balance the risks in the COVID-19 era.

The COVID-19 pandemic has led to a reduced colonoscopy capacity in the UK resulting in increased waiting times for investigation. To increase diagnostic capacity and reduce the risk of diagnostic delay, CT colonography (CTC) and colon capsule endoscopy (CCE) are increasingly being relied upon. Endoscopic assessment and treatment will be required for those patients with large colonic polyps or malignant tumours detected by CTC or CCE, provided they are fit enough to undergo further investigation. The management of patients with intermediate (6-9mm) and diminutive (<6mm) colonic polyps, reported by CTC and CCE, will increasingly be decided by clinicians. Published literature suggests the risk of progression to malignancy of intermediate or diminutive polyps over 3 years is low. Furthermore, the risk of intermediate or diminutive polyps harbouring malignancy is extremely low. The benefits, and timeline, for the removal of these polyps must be carefully considered for patients. We present a pragmatic approach to managing intermediate and diminutive polyps. We suggest delayed polypectomy (up to one year) for patients with intermediate polyps who are likely to benefit. For those patients with diminutive polyps, we advocate further surveillance only for younger patients where clinical concern exists. This meets the aspirations of Realistic Medicine, providing a risk-based approach for patients, while appropriately prioritising resources.