Gastroenterology is in many ways a technology-driven field. One might expect rapid gains and advancements; however, incorporation of new technology is not easy for many reasons. Most importantly this is medicine. It is not about the best gadget that will boost the bottom line. We need to do right by our patients and their health. We need proof that a new technology works and that it can be implemented effectively and safely.

The approach to small polyps is a good example of how difficult it is to advance the field through technology. We have developed better imaging techniques—narrow band imaging (NBI), Fujinon intelligence chromoendoscopy, iScan and others—with the promise to predict polyp histology real time.1 ,2 Especially for diminutive polyps, real time diagnosis may improve efficiency, lower cost and improve patient safety.3–5

But what is really needed to bring real time polyp diagnosis into clinical practice? The American Society of Gastrointestinal Endoscopy led Preservation and Incorporation of Valuable endoscopic Innovations (PIVI) initiative has provided a roadmap and suggested thresholds that need to be met before incorporating two changes to our clinical practice of polyp resection:2

1. Confidently diagnosed diminutive polyps can be resected and discarded if the recommended surveillance interval that is based on real time diagnosis agrees with the surveillance interval based on the pathology in at least 90% of patients.

2. Confidently diagnosed diminutive hyperplastic …