“Resect and pool”: surveillance interval agreement, safety, and savings from placing all colorectal polyps considered zero risk for cancer in one container for pathologic assessment

Abstract

Background

We investigated the effects of collecting all lesions (from all segments) deemed zero risk for cancer in a single bottle for pathology.

Methods

We performed two prospective evaluations. In phase 1, resected zero-risk lesions from the same segment were collected in the same bottle. The endoscopist predicted surveillance intervals based on lesion size, number, and histology predictions. Predicted intervals were compared with pathology-based intervals. In phase 2 the “resect and pool” strategy was implemented, in which all zero-risk lesions from all segments were collected in a single bottle. End points were proportion of correctly assigned surveillance intervals, safety (no cancers placed with lesions from other segments), and savings (reduction in pathology bottles and carbon emissions).

Results

In phase 1, 3514 lesions were deemed zero risk, and none had cancer. Of 72 non-zero-risk lesions, 6 (8.3%) had cancer. Endoscopist surveillance intervals were correct in 97.2% (95%CI 95.7%–98.2%) of procedures, and 97.1% (95%CI 95.1%–98.4%) when intervals were determined only by lesions from the current colonoscopy. Phase 2 had 5107 zero-risk lesions, and none had cancer. Combining zero-risk lesions from different segments in a single bottle reduced pathology costs and carbon footprint by 62%–64% compared with zero-risk lesions being separated by colorectal segment.

Conclusions

When performed by an endoscopist with expertise in optical diagnosis, resect and pool colonoscopy was safe, permitted correct prediction of surveillance intervals, and reduced pathology costs and carbon emissions.

Publication History

Received: 30 June 2025

Accepted after revision: 09 December 2025

Accepted Manuscript online:
10 December 2025

Article published online:
21 January 2026

• References

• 1 Shaukat A, Kahi CJ, Burke CA. et al. ACG clinical guidelines: colorectal cancer screening 2021. Am J Gastroenterol 2021; 116: 458-479
• 2 Halpern MT, Liu B, Lowy DR. et al. The annual cost of cancer screening in the United States. Ann Intern Med 2024; 177: 1170-1178
• 3 Yusuf H, Gupta V, Osaghae I. et al. Longitudinal impact of screening colonoscopy on greenhouse gas emissions. PLoS One 2024; 19: e0307133
• 4 Desai M, Campbell C, Perisetti A. et al. The environmental impact of gastrointestinal procedures: a prospective study of waste generation, energy consumption, and auditing in an endoscopy unit. Gastroenterology 2024; 166: 496-502.e493
• 5 Baddeley R, Aabakken L, Veitch A. et al. Green endoscopy: counting the carbon cost of our practice. Gastroenterology 2022; 162: 1556-1560
• 6 Maurice JB, Rochford A, Marshall S. et al. Green endoscopy: using quality improvement to develop sustainable practice. Frontline Gastroenterol 2022; 13: 342-345
• 7 Sebastian S, Dhar A, Baddeley R. et al. Green endoscopy: British Society of Gastroenterology (BSG), Joint Accreditation Group (JAG) and Centre for Sustainable Health (CSH) joint consensus on practical measures for environmental sustainability in endoscopy. Gut 2023; 72: 12-26
• 8 Crockett SD, Skole KS. Prepared by: American Society for Gastrointestinal Endoscopy Sustainable Endoscopy Task Force. et al. Practical steps to green your endoscopy unit: how to get started. Gastrointest Endosc 2023; 98: 889-892.e1
• 9 Rex DK, Gallagher JA, Lahr RE. et al. One-device colonoscopy: feasibility, cost savings, and plastic waste reduction by procedure indication, when performed by a high detecting colonoscopist. Endoscopy 2024; 56: 102-107
• 10 Ferlitsch M, Hassan C, Bisschops R. et al. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2024. Endoscopy 2024; 56: 516-545
• 11 Rex DK, Kahi C, O’Brien M. et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc 2011; 73: 419-422
• 12 Thosani N, Abu Dayyeh BK. ASGE Technology Committee. et al. ASGE Technology Committee systematic review and meta-analysis assessing the ASGE Preservation and Incorporation of Valuable Endoscopic Innovations thresholds for adopting real-time imaging-assisted endoscopic targeted biopsy during endoscopic surveillance of Barrett’s esophagus. Gastrointest Endosc 2016; 83: 684-698.e687
• 13 Rex DK. Making a resect-and-discard strategy work for diminutive colorectal polyps: let’s get real. Endoscopy 2022; 54: 364-366
• 14 Ponugoti PL, Cummings OW, Rex DK. Risk of cancer in small and diminutive colorectal polyps. Dig Liver Dis 2017; 49: 34-37
• 15 Rex DK, Boland CR, Dominitz JA. et al. Colorectal cancer screening: recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2017; 86: 18-33
• 16 Gupta S, Lieberman D, Anderson JC. et al. Recommendations for follow-up after colonoscopy and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2020; 115: 415-434
• 17 Jacobson BC, Anderson JC, Burke CA. et al. Optimizing bowel preparation quality for colonoscopy: consensus recommendations by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2025; 120: 738-764
• 18 Patel NJ, Ponugoti PL, Rex DK. Cold snare polypectomy effectively reduces polyp burden in familial adenomatous polyposis. Endosc Int Open 2016; 4: E472-474
• 19 American Pathology Foundation. Pathology Service Coding Handbook. Chicago, IL : American Pathology Foundation; 2025
• 20 Laboratory Economics newsletter: 19(12). Poughkeepsie, NY: Laboratory Economics LLC; 2024.
• 21 Gordon IO, Sherman JD, Leapman M. et al. Life cycle greenhouse gas emissions of gastrointestinal biopsies in a surgical pathology laboratory. Am J Clin Pathol 2021; 156: 540-549
• 22 Trecourt A, Cottinet PJ, Donzel M. et al. Carbon footprint evaluation of routine anatomic pathology practices using eco-audit: current status and mitigation strategies. Ann Diagn Pathol 2023; 67: 152210
• 23 Rex DK, Ponugoti P, Kahi C. The “valley sign” in small and diminutive adenomas: prevalence, interobserver agreement, and validation as an adenoma marker. Gastrointest Endosc 2017; 85: 614-621
• 24 Rex DK, Hardacker K, MacPhail M. et al. Determining the adenoma detection rate and adenomas per colonoscopy by photography alone: proof-of-concept study. Endoscopy 2015; 47: 245-250
• 25 Ponugoti P, Rastogi A, Kaltenbach T. et al. Disagreement between high confidence endoscopic adenoma prediction and histopathological diagnosis in colonic lesions ≤3mm in size. Endoscopy 2019; 51: 221-226
• 26 Vemulapalli KC, Rex DK. Failure to recognize serrated polyposis syndrome in a cohort with large sessile colorectal polyps. Gastrointest Endosc 2012; 75: 1206-1210
• 27 McWhinney CD, Lahr RE, Rex DK. Frequency of serrated polyposis syndrome recognition by community endoscopists. Endosc Int Open 2023; 11: E888-E892
• 28 Hewett DG, Kaltenbach T, Sano Y. et al. Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging. Gastroenterology 2012; 143: 599-607.e591
• 29 MacPhail ME, Thygesen SB, Patel N. et al. Endoscopic control of polyp burden and expansion of surveillance intervals in serrated polyposis syndrome. Gastrointest Endosc 2019; 90: 96-100
• 30 Yong KK, He Y, Cheung HCA. et al. Rationalising the use of specimen pots following colorectal polypectomy: a small step towards greener endoscopy. Frontline Gastroenterol 2023; 14: 295-299