Reuse of Polyp Traps, a Way to Approach Sustainability: A Multicentric Non-inferiority Study
Conditions: Cross Infection
Sponsor: Fundació Institut de Recerca de l'Hospital de la Santa Creu i Sant Pau

IIBSP-RPT-2024-69 
Protocol Identifying number: POLYPTRAP 
 
Version 1.0: 09-03-2024 
Confidential 
 
draft 
  
Reuse of polyp traps, a way to approach 
sustainability: A multicentric non-
inferiority study.  
 
Protocol identifying number: POLYPTRAP 
 
 
Confidentiality Statement 
This document contains confidential information that must not be disclosed to 
anyone other than the Sponsor, the Investigator Team, regulatory authorities, 
and members of the Ethics Committee.   
 
 
Sponsor: Institut de Recerca de l'Hospital de la Santa Creu i Sant Pau –  
IIB Sant Pau 
Investigator Coordinator: Dr. Carlos Guarner Argente 
 
 
 

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TABLE OF CONTENTS 
Page Number 
1. INTRODUCTION………………………………………………………………  3 
1.1 Background Information…………………………………………….. 
3 
1.2 Rationale or Justification……………………………………………. 
4 
2. OBJECTIVES AND PURPOSE…………………………………………….. 5 
2.1 Principal Objective……………………………………………………… 
5  
2.2 Secondary Objectives………………………………………………….. 5 
3. SOURCE OF INFORMATION AND DATABASE 
 
 
5 
4. TRIAL DESIGN………………………………………………………………… 5 
4.1 Summary of Trial Design……………………………………………. 
5 
4.2 Primary and Secondary Endpoints/Outcomes 
Measures……………………………………………………………………... 6 
5. STUDY POPULATION…………………………………………………….. 7 
5.1 Inclusion criteria………………………………………………………. 
7 
5.2 Exclusion criteria……………………………………………………… 
7 
6. STUDY PROCEDURES……………………………………………………. 
7 
6.1 Informed consent……………………………………………………… 
7 
7. STATISTICAL METHODS AND SAMPLE SIZE…………………… 
8 
7.1 Statistical Analysis…………………………………………………….. 
8 
7.2 Sample Size Calculation…………………………………………….. 
8 
8. DIRECT ACCESS TO SOURCE DATA/DOCUMENTS………….. 
9 
9. ETHIC, DEONTOLOGICAL AND REGULATORY 
CONSIDERATIONS……………………………….………………………… 9 
10. DATA HANDLING AND RECORD KEEPING……………………… 
9 
11. REFERENCES…………………………………………………………………. 10 
Attachment A: Data form 
 
 
 
 
 
12 
Attachment B: Information for the patient  
 
 
13 
Attachment C: Informed consent 
 
 
 
 
13 
 
 

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1. INTRODUCTION 
 
1.1 
BACKGROUND INFORMATION 
Climate change is the phenomenon of increase of the global temperature because of greenhouse gas 
(GHG) emissions (1) which is one of the main concerns of humanity and it has a huge impact on human 
health. This impact is not only direct due to the effect of heat waves or to the consequences of extreme 
weather events, but also indirect due to the modifications that generates in ecosystems, economies 
and social structures (2).  
The four major GHGs are: carbon dioxide, methane, nitrous oxide and industrial gases as fluorinated 
gases. Considering that not all GHGs affect equally to global warming, a standardised unit, the carbon 
dioxide equivalents (CO2e), is used to quantify GHG emissions allowing to measure the equivalent 
global warming impact (3). Higher temperatures produced by GHG emissions increase the 
transmission of infectious diseases (4), puts in risk food and water security leading to malnutrition and 
famine, and prompts the loss of biodiversity (1), among others. 
The Paris Agreement set in 2016 was a landmark in the multilateral climate change process as it was 
the first time a binding agreement brought all nations aligned to fight climate change (5). Its primary 
goal was to limit the temperature increase to 2oC above pre-industrial levels by 2025 at the latest, and 
to achieve a 43% reduction by 2030 (5).   
Climate change has a huge impact on human health but, paradoxically, the healthcare provision 
contributes to global warming and therefore to human health (1,6). Healthcare climate footprint is 
equivalent to 4.4% of the global net emissions worldwide (6–9). These emissions can be classified in 3 
scopes: scope 1) direct emissions caused by healthcare facilities and healthcare vehicles, which 
suppose the 17% of the sector’s worldwide footprint; scope 2) emissions related to purchased energy 
sources, which make up the 12%; and scope 3) indirect emissions caused by packaging, transport and 
production of food products, goods, services, and consumables , which constitute the remaining 71% 
(7,9,10). Europe is the third contributor to the healthcare climate footprint, behind China and the 
United States (9). In Spain, the healthcare sector contributes 4.5% to the total national footprint (9). 
Healthcare must respond to the growing climate emergency, not only by treating the health 
consequences, but also by radically reducing its own emissions (9).  
Endoscopy Units are considered the third highest contributors to the healthcare carbon footprint and 
generation of waste (1,11), due to the large volume of procedures performed and to the high amount 
of garbage generated (3). This fact should not be underestimated as 18 million endoscopy procedures 
are performed each year in the USA (3).  
A single endoscopy generates about 1.5 kg of plastic waste (3) and 28.4 kg of CO2e (11). The daily 
material of the endoscopic unit, included in scope 3, mainly consists of consumables, which are plastic-
predominant and not recycled (3). Each patient may require multiple one-use products, such as: 
privacy gowns, plastic bags for personal belongings, intravenous cannulas with dressing, soakers, 
syringes with medication and gauzes. For the endoscopy procedure, specific devices such as biopsy 
forceps, snares, diathermy pads, histology pots and many others may also be needed. Many of these 

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devices used to be reusable, but they have become single-use in recent decades without solid scientific 
data supporting the change (12). The main reasons for this change are the fear of patient cross-
contamination and the manufacturer’s pressure. However, for most devices, this risk has not been 
demonstrated or could be clinically insignificant. In fact, the use of single use material has been 
controversial, especially for devices that penetrate the epithelial barrier (3,13), but several studies 
suggest that the risk of cross contamination attributable to the reuse of this material should be 
reconsidered when adequately reprocessed and disinfected (13,14). Hence, we should reconsider 
using single-use devices taking into account its higher financial costs and environmental impact (12). 
The European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of 
Gastroenterology and Endoscopy Nurses and Associates (ESGENA) have published a position 
statement with a specific section for single use material suggesting that there is an urgent need to 
reassess and reduce the environmental and economic impact of single-use endoscopic devices (13). 
The ESGE-ESGENA recommends conducting research to quantify and minimise the environmental 
impact of GI endoscopy and include in future clinical guidelines and regulations aspects like the 
reprocessing and disinfection of single use devices (13). This is undoubtedly impossible to achieve 
without the support of the manufacturers. 
The polyp trap is a device used to collect polyps removed from intestinal mucosa. Made of plastic, it 
comprises multiple wells where different samples can be collected. The polyp trap is connected on 
one side to the endoscope extraction exit and to the suction tube on the other side. According to the 
manufacturers, it is a single-use device and must be replaced between patients. However, the polyp 
trap has a low probability of cross-contamination with the patient after washing, as fluids circulate 
unidirectionally from the endoscope to the suction device and are never in direct contact with the 
patient. Before its introduction, polyps were collected with simpler alternatives, such as the use of 
gauzes. However, they are increasingly being used in endoscopy units. At the Hospital de Sant Pau we 
used approximately 3800 polyp traps the last year. This represents a cost of 5700€ and an increase in 
CO2e. Nevertheless, many endoscopy units already reuse polyp traps in their clinical practice. 
Therefore, we aim to analyse the risks, costs and CO2e of using single-use polyp traps or reusing them. 
 
1.2 
RATIONALE OR JUSTIFICATION  
Our study falls within the sustainable endoscopy (“Green Endoscopy”) and responds to the call of the 
ESGE and the Spanish Society of Digestive Endoscopy (SEED) to carry out research that helps to design 
future clinical guidelines considering reprocessing and disinfection of single-use material (13). 
Hopefully, our results may push manufacturers to rethink and facilitate the production of reusable 
devices. That could have a positive impact on the endoscopy footprint as it could reduce scope 3 
emissions. 
This measure, designed to reduce the environmental impact of the unit, has been prioritised following 
the 2x2 decision matrix on the relative cost (effort) and benefits of reducing carbon emissions 
proposed by Hernandez LV et al (1). Its implementation would require very little effort for the entire 
team, it would fit in with the already established endoscopy unit dynamics and does not imply an 
additional economic expense, but rather a reduction on the number of devices used. In relation to the 
reduction of CO2 emissions, every action counts, and reducing is more effective than reusing, which is 

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more effective than recycling (1). Establishing actions that have high adherence by the team is 
paramount to success. 
The aim of this study is to observe and evaluate whether there is any difference between the incidence 
of post-endoscopy infection, pathology results, costs, and CO2e in those centres in which the polyp 
trap was discarded or reused, to evaluate the security and possible benefits of reusing polyp traps. 
 
2. OBJECTIVES AND PURPOSE 
2.1 
PRINCIPAL OBJECTIVE  
To evaluate whether the rate of infection is similar after colonoscopies using a reused or a disposed 
polyp trap.  
2.2 
SECONDARY OBJECTIVES 
1. To evaluate the risk of postprocedural fever after colonoscopy with a reused or a disposed polyp 
trap.  
2. To evaluate the risk of error in the anatomopathological study, due to persistence of biological 
material in a reused polyp trap. 
3. To estimate the carbon footprint of discarding and reusing polyp traps. 
4. To calculate the cost of discarding and reusing polyp traps. 
5. To assess other complications of the procedure (bleeding, perforation). 
 
3. SOURCE OF INFORMATION AND DATABASE 
Data about patients and endoscopy will be collected immediately before and after the endoscopy.  
Follow-up will consist in a centralised telephonic interview 7 days later. When considered necessary, 
a review of the medical records will be performed by each participant centre investigators. Data will 
be collected in the platform RedCap. 
 
4. TRIAL DESIGN 
4.1 
SUMMARY OF TRIAL DESIGN 
This is a non-commercial, prospective, observational, non-inferiority study to evaluate whether 
reusing or discarding polyp traps after colonoscopy has a similar infection rate. Participant hospitals 
will be separated into two groups, according to their standard clinical practice: A) reuse or B) dispose 
polyp traps after a colonoscopy with polypectomy. Centres will participate with their current method 

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of using polyp traps. Work dynamics will not change as patients will be recruited from centres that 
routinely reuse or dispose polyp traps. 
All colonoscopies in which a polyp trap has been used will be included. Patient and Endoscopy 
information will be recorded at the moment of the colonoscopy, except for the evaluation of the 
pathology report, which will be performed 10-15 days after the procedure. This information will be 
sent daily to the IP institution through the electronic report. At the IP institution there will be an 
investigator in charge of the phone contact follow-up for all the patients. Patient, endoscopy and 
follow up information will be recorded according to the CRF included in the Attachment A. In case of 
adverse events requiring hospitalisation, medical records will be reviewed by the endoscopist at each 
institution.  
The duration of the participation for each patient in the clinical trial is 7 days or, in case of 
complication, until it is solved. The day of the procedure the patient will obtain the protocol 
information, and the informed consent will be obtained. 
4.2 
PRIMARY AND SECONDARY ENDPOINTS/OUTCOME MEASURES 
Primary endpoint:  
● To evaluate whether the rate of infection is similar after colonoscopies using a reused or a 
disposed polyp trap: to calculate the rate of infection, all clinical suspicions of infection will 
be recorded. The infection can be defined as “confirmed” if there is a positive culture or if 
there is suspicion by clinical, laboratory, and image techniques (CT, MRI), and a positive blood 
culture is obtained. It will be defined as “suspected” when clinical and/or image is suggestive 
of infection (i.e. fever), but microbial confirmation is not obtained. This will be measured 
during patient’s follow up and recorded at the CRF. All confirmed or suspected infections will 
be evaluated by the study panel, to determine whether it can be associated to the polyp trap, 
to other endoscopy complications (such as perforation or bronchoaspiration), or non-related 
to the colonoscopy, and weather the infection was clinically relevant. The panel evaluating 
the case will not be informed about the proceeding centre of the patient, so they will be 
blinded to the reuse or not of the polyp trap. If resolution of the complication is longer than 
the study follow-up period, it will be extended until it is solved. Additionally, to determine the 
relation of the infection with the polyp trap, in the reused polyp trap group, each trap will be 
traced to detect related infections. 
Secondary endpoints: 
● To evaluate the risk of error in the anatomopathological study, due to persistence of 
biological material in a reused polyp trap: all anatomopathological reports will be reviewed. 
Results suspicious of cross-sampling (i.e. adenocarcinoma for a normal appearing polyp) will 
be recorded and analysed using the polyp trap traceability. 
● To estimate the carbon footprint of disposable versus reusable polyp traps using life cycle 
assessment methodology. 

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● To calculate the cost of disposable versus reusable polyp traps:  the type, unit cost and 
number of polyp traps used at each institution will be recorded, to determine total costs at 
each group. 
● To assess other complications of the procedure (bleeding, perforation): The other secondary 
outcomes pretend to assess other complications related to colonoscopy with trap use (such 
as bleeding or perforation). The diagnosis of bleeding or perforation after the procedure will 
be confirmed according to the protocol at each institution. The evaluation of these secondary 
outcomes will be performed during the procedure and all the follow up period and will be 
managed according to protocol for each event at each institution. All of them will be recorded 
at the CRF. If resolution of the complication is longer than the study period, follow up will be 
extended until it is solved. 
Procedure outcomes will be graded as “mild” if the patient is discharged in the initial 24 hours, 
without need of further interventions. They will be graded as “severe” if they require 
hospitalisation longer than 24 hours, radiological or endoscopic drainage, blood transfusion, 
or resuscitation manoeuvres. A “fatal” complication will be described if a related death occurs.   
 
5. STUDY POPULATION 
5.1 
INCLUSION CRITERIA 
● All patients who undergo an elective colonoscopy will be recruited for the study. 
● Written informed consent to participate in the study and willingness to be contacted by 
telephone for follow-up. 
5.2 
EXCLUSION CRITERIA 
● Patients who complete the colonoscopy without a polypectomy. 
● Patients who complete the colonoscopy without the use of a polyp trap. 
 
6. STUDY PROCEDURES 
6.1 
INFORMED CONSENT 
Patients’ informed consent will be obtained immediately before the colonoscopy. The participant 
must personally sign and date the latest approved version of the informed consent form before any 
study specific procedures are performed. 
Written and verbal versions of the Participant Information Sheet and Informed Consent (Attachment 
B) will be presented to the participants detailing no less than: the exact nature of the study; the 
implications and constraints of the protocol; the known side effects and any risks involved in taking 
part. It will be clearly stated that the participant is free to withdraw from the study at any time for any 
reason without prejudice to future care, and with no obligation to give the reason for withdrawal. 

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The participant will be allowed as much time as wished to consider the information, and the 
opportunity to question the Investigator, their GP or other independent parties to decide whether 
they will participate in the study. Written Informed Consent will then be obtained by means of 
participant dated signature and dated signature of the person who presented and obtained the 
informed consent. The person who obtained the consent must be suitably qualified and experienced 
and will have been authorised to do so by the Principal Investigator. A copy of the signed Informed 
Consent will be given to the participants. The original signed form will be retained at the study site.  
 
7. STATISTICAL METHODS AND SAMPLE SIZE 
7.1 
STATISTICAL ANALYSIS 
Patient demographic data (sex, age) will be used to assess baseline comparability of the study groups. 
This will be reported as means, standard deviations, or proportions and will be analysed using the χ2 
and Fisher exact test for qualitative variables and t test for quantitative parameters. 
One time use of single-use polyp traps is the standard of care, as it is the actual manufacturers’ 
recommendation. A comparable risk of infection when reusing traps would be acceptable. For this 
reason, for the analysis of the primary outcome, a non-inferiority study will be performed. The risk of 
infection will be reported as a proportion. The 95% confidence intervals for proportions will be 
analysed with the Wilson method. 
The secondary outcomes of carbon footprint, costs, and other endoscopy complications will be 
reported as total emissions (CO2 Kg equivalents) and total costs per group and will be analysed with t 
test. 
The secondary outcomes of other endoscopy adverse events will be reported as proportions and will 
be analysed with the χ2 and Fisher exact test. 
The statistical analysis will be performed at the end of the study period by a statistician of the sponsor 
institution, with the SPSS (v). 
7.2 
SAMPLE SIZE CALCULATION 
The present study was planned to evaluate the non-inferiority of reusing polyp traps versus discarding 
polyp traps in terms of post-procedure rate of infection (the primary endpoint of the study). Evidence 
about the rate of infection after an endoscopic procedure is scarce. It was previously estimated to be 
1 in 1.8 million endoscopic procedures but recent studies have suggested this could be a significant 
underestimation (15). According to the Ofstead et al (16) described rates of postendoscopy 
complications ranging from 0.5% to 3.4%, including fever, diarrhoea, abdominal pain, and other signs 
and symptoms that may indicate infection. We expect a very low infection rate of 0.2% in both groups, 
considering that the triplication of this risk to 0.6% would not be acceptable, then assuming a non-
inferiority margin (δ) of 0,4%, a unilateral α-error of 0.05, and a power (β-error) of 20%, and a low rate 
of losses (5%), a total of 3238 patients will be required to complete the analysis of the primary 
outcome. The samples size was calculated with Sample Power (v 3.0.1).  

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7.3 INTERIM ANALYSES AND STOPPING RULES 
An interim analysis is not planned. If there is an incidence of serious infections (those including need 
for surgery, endoscopic drainage, ICU management, prolonged admission to the hospital greater than 
7 days, or death) superior to 5%, the study will be temporarily stopped. Results will be compared 
among study groups, and the study will be terminated if significance or clinically relevant differences 
are observed. 
 
8. DIRECT ACCESS TO SOURCE DATA/DOCUMENTS  
Direct access will be granted to authorised representatives from the sponsor, host institution and the 
regulatory authorities to permit audits and inspections. 
 
9.  ETHIC, DEONTOLOGICAL AND REGULATORY CONSIDERATIONS 
The Investigator will ensure that this study is conducted in accordance with the principles of the 
Declaration of Helsinki (17), ICH Guidelines for Good Clinical Practice and in full conformity with 
relevant regulations. 
The protocol, CRF and any applicable documents will be submitted to an appropriate Ethics Committee 
(EC) and Regulatory Authority for written approval.  
All substantial amendments to the original approved documents will be also sent to an appropriate 
Ethics Committee (EC) and Regulatory Authority for written approval. 
The study staff will ensure that the participants’ anonymity is maintained.  The participants will be 
identified only by a participant ID number on the CRF and any electronic database. All documents will 
be stored securely and only accessible by trial staff and authorised personnel. The study will comply 
with the Data Protection Legislation which requires data to be anonymized as soon as it is mandatory 
to do so.   
 
10. DATA HANDLING AND RECORD KEEPING 
Data will be recorded in the platform RedCap according to the attached form (attachment A). The 
person introducing the data will be identified and the date will be recorded. For any further 
annotation, the name of the investigator and the date will also be recorded. The paper data will be 
stored under key protection. 
Once each case is completed, the data will be transferred and stored to an SPSS data sheet. The SPSS 
datasheet will also be stored under password protection.  
All data collected in paper and SPSS will be associated only to an anonymous research number. Patient 
identifiers will be stored in a separate data sheet along with the anonymous number key, also secured 

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under password protection. Patient identifiers will not be disclosed to anyone except for the 
researchers who are authorised to be involved in the project. The number key will be discarded after 
the data for an individual patient have been collected. 
Records will be stored at the GI department of PI investigator for 5 years after the end of the study. 
The PI and a researcher at the PI institution will be responsible for the data collection, recording and 
quality. 
 
11. REFERENCES 
1.  
Hernandez L V., Agrawal D, Skole KS, Crockett SD, Shimpi RA, von Renteln D, et al. Meeting 
the environmental challenges of endoscopy: a pathway from strategy to implementation. 
Gastrointest Endosc [Internet]. 2023;98(6):881-888.e1. Available from: 
https://doi.org/10.1016/j.gie.2023.07.031 
2.  
Watts N, Adger WN, Agnolucci P. Health and climate change: Policy responses to protect 
public health. Environnement, Risques et Sante. 2015;14(6):466–8.  
3.  
Siau K, Hayee B, Gayam S. Endoscopy’s Current Carbon Footprint. Tech Innov Gastrointest 
Endosc. 2021;344–52.  
4.  
Romanello M, McGushin A, Di Napoli C, Drummond P, Hughes N, Jamart L, et al. The 2021 
report of the Lancet Countdown on health and climate change: code red for a healthy future. 
Lancet. 2021;398(10311):1619–62.  
5.  
UNFCCC. The Paris Agreement [Internet]. [cited 2024 Feb 5]. Available from: 
https://unfccc.int/process-and-meetings/the-paris-agreement 
6.  
Lenzen M, Malik A, Li M, Fry J, Weisz H, Pichler PP, et al. The environmental footprint of 
health care: a global assessment. Lancet Planet Heal [Internet]. 2020;4(7):e271–9. Available 
from: http://dx.doi.org/10.1016/S2542-5196(20)30121-2 
7.  
Henniger D, Lux T, Windsheimer M, Brand M, Weich A, Kudlich T, et al. Reducing scope 3 
carbon emissions in gastrointestinal endoscopy: Results of the prospective study of the 
“Green Endoscopy Project Würzburg.” Gut. 2023;(scope 3):1–6.  
8.  
Tennison I, Roschnik S, Ashby B, Boyd R, Hamilton I, Oreszczyn T, et al. Health care’s response 
to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Heal 
[Internet]. 2021;5(2):e84–92. Available from: http://dx.doi.org/10.1016/S2542-
5196(20)30271-0 
9.  
Karliner J, Slotterback S, Boyd R, Ashby B, Steele K. Health Care’s Climate Footprint How the 
Health Sector Contributes. Arup [Internet]. 2019;(September):48. Available from: 
https://www.arup.com/perspectives/publications/research/section/healthcares-climate-
footprint 
10.  
Eckelman MJ, Huang K, Lagasse R, Senay E, Dubrow R, Sherman JD. Health care pollution and 
public health damage in the united states: An update. Health Aff. 2020;39(12):2071–9.  
11.  
Lacroute J, Marcantoni J, Petitot S, Weber J, Levy P, Dirrenberger B, et al. The carbon 
footprint of ambulatory gastrointestinal endoscopy. Endoscopy. 2022;55(10):918–26.  
12.  
Cunha Neves JA, Rodriguez De Santiago E, Pohl H, Lorenzo-Zúniga V, Cunha MF, Voiosu AM, 

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et al. Perspectives and awareness of endoscopy healthcare professionals on sustainable 
practices in gastrointestinal endoscopy: Results of the LEAFGREEN survey. Endoscopy. 2023;  
13.  
Rodríguez De Santiago E, Dinis-Ribeiro M, Pohl H, Agrawal D, Arvanitakis M, Baddeley R, et al. 
Reducing the environmental footprint of gastrointestinal endoscopy: European Society of 
Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy 
Nurses and Associates (ESGENA) Position Statement. Endoscopy. 2022;54(8):797–826.  
14.  
Nabi Z, Tang RSY, Sundaram S, Lakhtakia S, Reddy DN. Single-use accessories and endoscopes 
in the era of sustainability and climate change—A balancing act. J Gastroenterol Hepatol. 
2023;1–11.  
15.  
McCafferty CE, Aghajani MJ, Abi-Hanna D, Gosbell IB, Jensen SO. An update on 
gastrointestinal endoscopy-associated infections and their contributing factors. Ann Clin 
Microbiol Antimicrob [Internet]. 2018;17(1):1–6. Available from: 
https://doi.org/10.1186/s12941-018-0289-2 
16.  
Ofstead CL, Dirlam Langlay AM, Mueller NJ, Tosh PK, Wetzler HP. Re-evaluating endoscopy-
associated infection risk estimates and their implications. Am J Infect Control [Internet]. 
2013;41(8):734–6. Available from: http://dx.doi.org/10.1016/j.ajic.2012.10.008 
17.  
Association WM. World Medical Association Declaration of Helsinki: ethical principles for 
medical research involving human subjects. JAMA. 2013;310(20):2191–4.  
 
 

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Attachment A: Data form 
POLYPTRAP Data Form 
 
EXCLUSION CRITERIA:   Any polyp trap used during the procedure? 
Yes / No 
 
DEMOGRAPHICS 
 
 
 
 
 
  
Patient ID:  
 
 
Gender: M / F  
 
Institution: 
Age: 
 
 
 
 
MEDICAL HISTORY 
Active infectious process (at the moment of endoscopy): Yes / No 
 
 
Observations:     
 
 
ENDOSCOPY 
 
 
 
 
Date:  
 
Time:  
 
Endoscopic  
: 
⃝    Bleeding 
⃝    Perforation 
⃝    Bronchoaspiration 
⃝    Other:  
 
 
 
Comments: 
⃝    None 
 
 
 
For institutions reusing polyp traps: Polyp trap ID: 
 
 
ANATOMOPATHOLOGICAL RESULT Consistent with findings in the endoscopy / Inconsistent  
(if inconsistent, add comment) 
 
FOLLOW-UP 
A) Any symptoms suggesting infection 
⃝    Fever 
⃝    Bacteraemia 
⃝    Bronchoaspiration / Pneumonia 
⃝    Other:  
 
 
 
Comments: 
⃝    None 
 
Event related to endoscopy: Yes / Probably / Doubtfully / No 
Event related to polyp trap: Yes / Probably / Doubtfully / No 
 
B) Other adverse events:  Yes / No   
Type: Bleeding / Perforation / Others 
 
Comment: 
 
C) Need of hospitalisation 
Yes / No 
D) Need of admission in intensive care unit 
Yes / No 
E) Fatal outcome 
Yes / No 
 
Comments: