Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.
World J Gastrointest Endosc. Nov 16, 2026; 18(11): 126001
Published online Nov 16, 2026. doi: 10.4253/wjge.126001
Colorectal polyp size measurement comparing biopsy forceps with visual assessment during real-time colonoscopy: A prospective, multicenter, international study
Demi Gerritsen, Milou L M van Riswijk, Douglas K Rex, Seth A Gross, Omer Goldstein, Nathaniel A Cohen, Safwat Odeh, Dana Ben-Ami Shor, Arjun D Koch, Vincent Rijckborst, Peter D Siersema
Demi Gerritsen, Arjun D Koch, Vincent Rijckborst, Peter D Siersema, Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam 3015 GD, South-Holland, Netherlands
Milou L M van Riswijk, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen 6525 GA, Gelderland, Netherlands
Douglas K Rex, Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN 46202, United States
Seth A Gross, Department of Gastroenterology, New York University Langone Health, New York, NY 10016, United States
Omer Goldstein, Safwat Odeh, Department of Gastroenterology, Bnai Zion Medical Center, Haifa 31048, Israel
Nathaniel A Cohen, Dana Ben-Ami Shor, Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
Co-first authors: Demi Gerritsen and Milou L M van Riswijk.
Author contributions: van Riswijk MLM designed the study and got medical ethical approval; Gerritsen D and van Riswijk MLM coordinated the study, and contributed equally to this work as co-first authors; Gerritsen D collected the data, analyzed the data, and drafted the manuscript; Rex DK, Gross SA, Goldstein O, Cohen NA, Odeh S, Ben-Ami Shor D, and Rijckborst V performed the endoscopies; van Riswijk MLM, Rex DK, Gross SA, Goldstein O, Cohen NA, Odeh S, Ben-Ami Shor D, Rijckborst V, Koch AD, and Siersema PD reviewed the draft; Koch AD aided in data interpretation; Siersema PD was involved in the study design; all authors approved the final version to publish.
AI contribution statement: The authors confirm that no AI tools were used at any stage during the manuscript preparation.
Supported by VTM Technologies.
Institutional review board statement: This study was reviewed and approved by the Ethical Review Board of METC Oost-Nederland, No. NL80961.091.22.
Informed consent statement: All patients who participated in this study provided their written informed consent prior to study enrolment.
Conflict-of-interest statement: Peter D Siersema has been an advisor on the VTM medical board. The other authors declare no conflicts of interest.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: Data that supports the findings of this study is available on request from the corresponding author, Demi Gerritsen. Data is not publicly available due to information that could compromise the privacy of research participants.
Corresponding author: Demi Gerritsen, MSc, Doctorate Student, Department of Gastroen
terology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Dr. Molewaterplein 40, Rotterdam 3015 GD, South-Holland, Netherlands.
d.gerritsen@erasmusmc.nl
Received: July 22, 2026
Revised: September 9, 2026
Accepted: October 26, 2026
Published online: November 16, 2026
Processing time: 114 Days and 14.1 Hours
BACKGROUND
Colorectal polyp size is important for assigning appropriate surveillance intervals, but conventional visual assessment (VA) often results in size misclassification. The use of a biopsy forceps (BF) might improve polyp size assessment as suggested in current guidelines.
AIM
To compare measurement performance of BF-assisted size measurement with VA during real-time colonoscopy.
METHODS
A prospective, multicenter, international study was conducted at 5 tertiary hospitals. Patients aged ≥ 18 years scheduled for screening, surveillance, or diagnostic colonoscopy were included. Polyps were measured during colonoscopy with VA, BF, and a laser system (reference standard) and then removed and sent for histopathological assessment. The primary outcome was inter-method agreement of BF and VA compared to laser-based size measurement. Secondary outcomes included inter-method agreement between BF and VA and size misclassification. Furthermore, clinical implications were explored.
RESULTS
Among 110 patients, 276 polyps were detected, including 138 with successful reference laser-based measurements, of which 137 were analyzed. Moderate agreement was found for BF and VA compared to laser measurements (κ = 0.534 vs 0.514) with wide limits of agreement (± 3 mm), while almost perfect agreement (κ = 0.863) was observed between BF and VA. Both BF and VA underestimated polyp size by -0.16 mm and –0.11 mm, underestimating around 14%-50% of > 5 mm and ≥ 10 mm polyps and overestimating approximately 2%-11% of ≤ 5 mm and < 10 mm polyps. Around 2% of patients were assigned an incorrect surveillance interval using BF and VA, and when implementing a resect-and-discard strategy, 11% of ≤ 5 mm polyps would have undergone histopathology and 14% of > 5 mm polyps would have been discarded.
CONCLUSION
BF-assisted size measurement performs similarly to conventional VA, without improving precision or reducing size misclassification. Thus, BF can unlikely replace VA in routine colonoscopy, nor be recommended in clinical guidelines.
Core Tip: Colorectal polyp size is visually assessed (VA) during colonoscopy, often causing misclassification and potentially leading to incorrect surveillance intervals. Biopsy forceps (BF)-assisted size measurement is recommended by European and American societies guidelines as it potentially reduces VA-related bias; however, its added value over VA is poorly studied. We prospectively evaluated measurement performance of BF and VA against reference laser-based measurements. Both techniques showed only moderate agreement with wide limits of agreement and resulted in a 2%-50% size misclassification. In contrast, BF and VA demonstrated almost perfect agreement with each other, suggesting limited added value of BF to VA.
