Colonic polyps are common and frequently encountered during optical colonoscopy (OC) [1]. The association between adenomas of the large bowel and colorectal cancer (CRC) is well established [2]. Polypectomy is carried out when polyps are identified at OC, to reduce the risk of CRC developing [3]. The relative risk of adverse events is greater for those undergoing therapeutic OC compared with diagnostic OC, but the absolute risk remains low [4]. Overall, for most patients the benefits of polypectomy outweigh the risks.

Colonoscopy capacity in the United Kingdom has been reduced significantly due to the effects of the COVID-19 pandemic [5]. Clinicians are rightly concerned about the risk of a delayed diagnosis of CRC caused by prolonged waiting times for investigation, and the risk of COVID transmission to patients or staff involved in supporting invasive procedures. National efforts are being made to mitigate these risks [6-8]. This has led to a greater reliance on alternative colonic investigations, namely CT colonography (CTC) and colon capsule endoscopy (CCE). While accurate at detecting colonic pathology, these investigations will necessitate some patients undergoing follow-up endoscopic procedures to biopsy or treat pathology [9]. The use of the faecal immunochemical test (FIT) has also been advocated as an adjunct to clinical acumen to help triage patients, given its ability to determine the risk of patients harbouring significant bowel pathology [10-12]. CTC or CCE can therefore be used to reduce the risk of diagnostic delay in those with intermediate FIT results by providing additional diagnostic capacity [13].

Consequently, as the use of CTC and CCE increases, clinicians will more frequently have to determine how best to manage patients in whom polyps have been reported. Malignant pathology, or large polyps (≥10 mm), found by CTC or CCE, will inevitably require luminal assessment in an appropriate timeframe, provided that the patient is fit enough to undergo further investigation or therapeutics, in concordance with the principles of Realistic Medicine [14, 15]. Patients with multiple polyps (≥5) are at greater risk of developing colorectal cancer in the future and therefore warrant OC to remove these, regardless of size [16. However, there is less consensus on the decision-making for intermediate polyps (6–9 mm) and diminutive polyps (<6 mm).

The published literature on intermediate polyps suggests that the risk of progression to malignancy over 3 years is extremely low and only 6% may progress to advanced adenomas (≥10 mm size, contain high-grade dysplasia or villous features) [17-19]. In a large series reported by Ponugoti et al., the majority of intermediate polyps showed no concerning features on histopathological assessment with only 0.8% found to have high-grade dysplasia and there were no cancers [20]. These results confirm that a minority of intermediate polyps will advance and, therefore, careful consideration on the need for removal is required when they are reported on CTC and CCE. For elderly patients, in whom significant colonic pathology has been excluded, removal of intermediate polyps is likely to be futile. For younger patients with intermediate polyps, delayed polypectomy should be considered. This would carry limited clinical risk and provide greater immediate utility of OC appointments for endoscopy units. The timeframe for intervention will depend on OC availability, but there is no evidence to suggest patients would be harmed by waiting up to 1 year.

Diminutive polyps are considered at a lower level of risk compared with intermediate polyps. National CTC guidelines advocate that diminutive polyps are not reported if detected [21]. In addition, there is an acceptance that low risk adenomas will be missed using FIT at a cut-off of 10 µg/g in symptomatic patients. Furthermore it has also been reported that the risk of subsequent CRC in this group is very low and safety netting is not being advocated [11]. Due to the nature of the test, CCE is much more likely to report diminutive polyps. Polypectomy for diminutive polyps in elderly patients is similarly difficult to justify given the low risk of the polyps progressing within the patients’ lifetime. Younger patients with diminutive polyps should be encouraged to participate in a national bowel screening programme when invited; this will provide an adequate safety net. Clinicians may feel uncomfortable about leaving diminutive polyps in younger patients who are at least 5 years from the bowel screening age given the risk of progression in the longer term. Therefore, clinicians could consider offering surveillance OC within 5 years to minimize future risk.

A pragmatic approach to dealing with intermediate and diminutive polyps is therefore needed whilst the current focus of endoscopy resources is on the detection of CRC. The merits of timely polypectomy for intermediate and diminutive polyps seem low, particularly in the current circumstances. Delayed polypectomy would seem appropriate for those patients with intermediate polyps, giving endoscopy units greater flexibility in scheduling appointments, akin to providing a bar in a busy restaurant – it will help flow. This strategy, however, assumes that the current endoscopy backlogs are reduced and further capacity will be generated in the future. For polyps <6 mm, a clinical consensus is needed to support decision-making and we propose a pragmatic algorithm (Figure 1). This approach is commensurate with the principle of Realistic Medicine and would enable a shift in clinical practice away from a “zero risk” policy for all, which is becoming increasingly difficult to resource, towards one which more appropriately prioritises resource for those patients in the highest risk groups and who have the most to gain from interventions – an approach which should deliver better and more appropriate clinical care for all patients [15].

结肠息肉在光学结肠镜检查 (OC) [ 1 ]中很常见且经常遇到。大肠腺瘤与结直肠癌 (CRC) 之间的关联已得到充分证实 [ 2 ]。当在 OC 发现息肉时进行息肉切除术，以降低发生 CRC 的风险 [ 3 ]。与诊断性 OC 相比，接受治疗性 OC 的患者发生不良事件的相对风险更高，但绝对风险仍然很低 [ 4 ]。总体而言，对于大多数患者而言，息肉切除术的益处大于风险。

由于 COVID-19 大流行 [ 5 ]的影响，英国的结肠镜检查能力已显着降低。临床医生正确地担心因等待调查时间延长而导致延迟诊断 CRC 的风险，以及将 COVID 传播给参与支持侵入性手术的患者或工作人员的风险。各国正在努力减轻这些风险 [ 6-8 ]。这导致更多地依赖替代结肠检查，即 CT 结肠造影 (CTC) 和结肠胶囊内窥镜检查 (CCE)。虽然在检测结肠病理学方面准确，但这些调查将需要一些接受后续内窥镜手术的患者进行活检或治疗病理学 [ 9]。粪便免疫化学测试 (FIT) 的使用也被提倡作为临床敏锐度的辅助手段，以帮助对患者进行分类，因为它能够确定患有严重肠道病变的患者的风险 [ 10-12 ]。因此，CTC 或 CCE 可用于通过提供额外的诊断能力来降低具有中等 FIT 结果的患者的诊断延迟风险 [ 13 ]。

因此，随着 CTC 和 CCE 使用的增加，临床医生将更频繁地必须确定如何最好地管理已报告息肉的患者。CTC 或 CCE 发现的恶性病变或大息肉 (≥10 mm) 将不可避免地需要在适当的时间范围内进行管腔评估，前提是患者足够健康，可以接受进一步的调查或治疗，符合现实医学的原则[ 14、15 ]。患有多发性息肉 (≥5) 的患者未来患结直肠癌的风险更大，因此无论大小如何，都需要 OC 切除这些息肉 [ 16 . 然而，对于中间型息肉（6-9 mm）和小息肉（<6 mm）的决策制定的共识较少。

已发表的关于中间息肉的文献表明，3 年内进展为恶性肿瘤的风险极低，只有 6% 可能进展为晚期腺瘤（≥10 毫米大小，包含高度不典型增生或绒毛特征）[ 17-19 ]。在 Ponugoti 等人报道的大型系列中，大多数中间息肉在组织病理学评估中没有表现出令人担忧的特征，只有 0.8% 发现有高度不典型增生并且没有癌症 [ 20]。这些结果证实少数中间息肉会进展，因此，在 CTC 和 CCE 报告它们时，需要仔细考虑是否需要切除。对于已排除显着结肠病变的老年患者，去除中间息肉可能是徒劳的。对于中度息肉的年轻患者，应考虑延迟息肉切除术。这将带来有限的临床风险，并为内窥镜检查单位的 OC 预约提供更大的直接效用。干预的时间框架将取决于 OC 的可用性，但没有证据表明患者会因等待长达 1 年而受到伤害。

与中度息肉相比，小型息肉被认为具有较低的风险水平。国家 CTC 指南主张，如果发现小息肉，则不报告 [ 21 ]。此外，在有症状的患者中，以 10 µg/g 的临界值使用 FIT 会漏诊低风险腺瘤。此外，据报道，该组随后发生 CRC 的风险非常低，并且不提倡使用安全网 [ 11]。由于测试的性质，CCE 更有可能报告小型息肉。考虑到患者一生中息肉进展的风险低，老年患者的小息肉切除术同样难以证明其合理性。应鼓励患有小息肉的年轻患者应邀参加国家肠道筛查计划；这将提供一个足够的安全网。考虑到长期进展的风险，临床医生可能会对在肠道筛查年龄至少 5 年的年轻患者中留下小息肉感到不舒服。因此，临床医生可以考虑在 5 年内提供监测 OC，以最大限度地降低未来风险。

因此，需要一种实用的方法来处理中型和小型息肉，而目前内窥镜检查资源的重点是检测 CRC。对于中型和小型息肉，及时切除息肉的好处似乎很低，尤其是在目前的情况下。延迟息肉切除术似乎适合中度息肉患者，让内窥镜检查部门在安排预约方面具有更大的灵活性，类似于在繁忙的餐厅提供酒吧——这将有助于流动。然而，这种策略假设当前的内窥镜积压减少，未来将产生更多的能力。对于 <6 mm 的息肉，需要临床共识来支持决策，我们提出了一种实用的算法（图 1）。15 ]。