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Background and Aims The most commonly detected polyps during screening colonoscopy are diminutive and small polyps, and therefore endoscopic treatment of those polyps is a daily routine for every colonoscopist. The primary aim of this study was to compare the complete eradication rate of diminutive and small colorectal polyps using cold biopsy versus other techniques, because randomized controlled trials have shown conflicting results. Methods In March 2015 we searched for randomized controlled trials in Medline, EMBASE, and ISI the Web of Science, starting with their dates of inception, and abstracts of pertinent scientific meetings (eg, American College of Gastroenterology, Digestive Disease Week). The primary outcome was complete removal of diminutive and small polyps (≤7 mm) by histologic eradication rates. The secondary outcome was total procedure time. Using RevMan (Cochrane), we used the Mantel-Haenszel random effects model for binary endpoints and the inverse variance method for continuous outcomes. Grading of Recommendations Assessment, Development and Evaluation was used to rate the quality of evidence for each outcome. Results Five randomized controlled trials included a total of 668 patients and 721 polyps. Removal techniques included cold biopsy, jumbo biopsy, and cold snare polypectomy. Based on histologic criteria, incomplete polyp removal was significantly lower with cold snare/jumbo forceps biopsy technique than with the cold biopsy technique (relative risk, .40; 95% CI, .26-.62), with no heterogeneity (I 2 , 0%). Total procedure time was an average of 2.66 minutes shorter for the cold snare/jumbo forceps biopsy techniques compared with the cold biopsy technique (95% CI, –5.14 to –.18). The quality of evidence was rated moderate. Conclusions There is moderate quality evidence that cold snare or jumbo biopsy techniques reduce the risk of incomplete diminutive polyp removal by 60% without increasing the total procedure time. Adequately powered randomized clinical trials are warranted to confirm these findings.

Background Current guidelines recommend consideration of screening patients with chronic GERD for Barrett's esophagus (BE). Unsedated esophagoscopy (UE) is a less costly alternative to standard EGD for identifying BE. The aim of this study was to determine the indications for EGD referral, the barriers to screening, and the interest in performing UE. Methods A one-page survey was mailed to a random sample of 500 family practitioners and 500 internists. This sample was obtained from the American Academy of Family Physicians and American Society of Internal Medicine (500 from each organization). Results The overall response rate was 54%. The majority (78%) refer more than 50% of their GERD patients for EGD; however, 34% also refer more than 10% of their patients for barium studies. Primary care physicians cited alarm symptoms, refractory symptoms, and chronicity and severity of symptoms as the major indications for referral for EGD. Gender, age, obesity, and tobacco use were cited less frequently. Cost of endoscopy, poor patient acceptance, and lack of evidence were the most common reasons cited for not referring for EGD. A majority of respondents (62%) indicated that the availability of UE would increase referral for the procedure, and 52% would be willing to perform UE in their office. Conclusions Severe, refractory, and chronic symptoms are the primary reasons for endoscopic referral from primary care physicians who manage patients with GERD. Other risk factors for BE, such as gender and age, do not appear to be important determinants for endoscopic referral. Further evaluation of UE as a mechanism to increase screening for BE in primary care patients is merited.

Background: Unsedated esophagoscopy with small-diameter endoscopes is generally well tolerated but of limited sensitivity for the diagnosis of esophageal mucosal disease. This study evaluated the sensitivity of esophagoscopy performed with new 4-mm diameter prototype battery-powered and video endoscopes. Patient tolerance for an unsedated examination with the 4-mm endoscopes was assessed and the performance characteristics of the battery-powered and video 4-mm endoscopes were compared. Methods: Patients referred for EGD were recruited to undergo an additional examination with a 4-mm endoscope. A prototype 60-cm long, 4-mm diameter battery-powered fiberoptic esophagoscope was used in the first 24 patients and a prototype 60-cm long, 4-mm diameter video esophagoscope in the next 27 patients. Examiners who were unaware of patient history and procedure indications recorded esophageal findings, ease of intubation, optical quality (5-point visual scale), and time for examination of the esophagus and then recorded esophageal findings after the standard EGD. Results: The sensitivity, specificity, and accuracy for identification of Barrett's esophagus was 100%; overall sensitivity, accuracy, and specificity for detecting esophageal lesions were, respectively, 91%, 98%, and 99%. Patient tolerance (assessed by symptom scores for choking, pain, and discomfort) and acceptability of unsedated esophagoscopy with the 4-mm diameter instruments were significantly better than in a historical group of patients examined with a 3-mm diameter endoscope. The optical quality of video endoscope was rated as superior to that of battery-powered endoscope, and esophageal examination was performed significantly quicker with the video versus the battery-powered endoscope (68 vs. 137 seconds; p = 0.001). Conclusions: Unsedated esophagoscopy with 4-mm diameter endoscopes may be an alternative to EGD for screening for Barrett's esophagus. Given the current state of endoscopic technology, a minimum diameter of 4 mm is required for satisfactory esophageal imaging. (Gastrointest Endosc 2003;57:300-4.)