A Pilot Randomized Trial of Polypectomy Techniques for 4 to 6 mm Colonic Polyps.

Colonoscopy has been shown to reduce the risk of colon cancer by enabling the removal of precancerous lesions. Although cold snare and hot snare polypectomy have similar retrieval rates and complete resection rates, rates of delayed bleeding tend to be lower with cold snare polypectomy than with hot snare polypectomy, especially for patients taking antithrombotic agents. However, among cold snares there may be differences in terms of the completeness of polyp excision, as complete removal appears more likely with thin-wire dedicated cold snares compared to the traditional, thick-wire cold snares. Cold snare polypectomy may be especially well suited for use in patients taking antithrombotic agents, due to its minimal risk of delayed bleeding. Histological analyses suggest that cold snare polypectomy causes less damage to blood vessels in the submucosal layers, which results in a reduced incidence of hemorrhage compared to hot snare polypectomy. However, cold snare removal of small polyps may result in fragmentation of small specimens during collection and concerns as to whether the resection is complete. An endoscopy biomarker of effective cold snare polypectomy technique is needed to ensure complete removal of non-pedunculated colorectal polyps ≤10mm. Future uses of cold snare polypectomy may include piecemeal removal of sessile serrated adenoma/polyp lesions >10mm. Currently, cold snare polypectomy should be considered a primary method for colorectal polyps of less than 10mm, especially those in the 4- to 10-mm range.

Width and depth of resection for small colorectal polyps: hot versus cold snare polypectomy

Resection techniques for small polyps include cold snare polypectomy (CSP) and hot snare polypectomy (HSP). This study compared CSP and HSP in 5-9 mm polyps in terms of complete resection and adverse events. This was a multicenter, randomized trial conducted in seven Spanish centers between February and November 2019. Patients with ≥ 1 5-9 mm polyp were randomized to CSP or HSP, regardless of morphology or pit pattern. After polypectomy, two marginal biopsies were submitted to a pathologist who was blinded to polyp histology. Complete resection was defined as normal mucosa or burn artifacts in the biopsies. Abdominal pain was only assessed in patients without < 5 mm or > 9 mm polyps. 496 patients were randomized: 237 (394 polyps) to CSP and 259 (397 polyps) to HSP. Complete polypectomy rates were 92.5 % with CSP and 94.0 % with HSP (difference 1.5 %, 95 % confidence interval -1.9 % to 4.9 %). Intraprocedural bleeding occurred during three CSPs (0.8 %) and seven HSPs (1.8 %) (P = 0.34). One lesion per group (0.4 %) presented delayed hemorrhage. Post-colonoscopy abdominal pain presented similarly in both groups 1 hour after the procedure (CSP 18.8 % vs. HSP 18.4 %) but was higher in the HSP group after 5 hours (5.9 % vs. 16.5 %; P = 0.02). A higher proportion of patients were asymptomatic 24 hours after CSP than after HSP (97 % vs. 86.4 %; P = 0.01). We observed no differences in complete resection and bleeding rates between CSP and HSP. CSP reduced the intensity and duration of post-colonoscopy abdominal pain.

Background: The optimal method of diminutive polypectomy (< 6 mm) is unknown.Objective: To assess the rates of incomplete resection of diminutive polyps of the colon using three standard polyp resection techniques (hot snare, cold snare, and cold biopsy forceps).Design: Randomized, pilot study.Settings: Single-center endoscopy center.Patients: Patients undergoing routine outpatient colonoscopies.Interventions: Polypectomy was performed using the method to which the patient was randomized. Following retrieval of the polyp, the polypectomy base was lifted by submucosal injection of normal saline and then excised using the cold snare device. If no tissue could be removed, then at least four cold biopsies using forceps of the remaining margin were obtained.Main outcome measures: Adequacy of resection of diminutive polyps, which was defined as no visible adenoma or hyperplastic tissue seen in the base tissue on histology.Results: A total of 60 patients were enrolled (57 % male), the mean age was 60 (range 33 – 82), and 62 polyps were randomized from 37 patients. The mean polyp size was 3.6 mm (range 2 – 5 mm) and 37 polyps (60 %) were adenomatous. Overall incomplete polyp resection rate was 9 % (95 %CI 3 – 19 %), 5 of 37 (14 %) for adenomas. By the study arm, the incomplete resection rates were 1 of 18 (6 %) for hot snare, 2 of 21 (10 %) for cold snare, and 2 of 18 (11 %) for cold biopsy forceps. The majority of polyp bases were removed with cold biopsy forceps since most of the endoscopists did not feel that the saline lift cold snare method was feasible or appropriate.Limitations: Small sample size; endoscopic mucosal resection (EMR) of the polyp base tissue was not routinely performed.Conclusions: Recruiting patients to a pilot study that randomized polyps to one of three common methods of polypectomy for diminutive polyps was feasible, and approximately 1 in 10 diminutive polyps found on colonoscopy were incompletely resected by standard polypectomy methods.

Response:

Concerns regarding bleeding remain in cold snare polypectomy (CSP) for small pedunculated (0-Ip) polyps. The aim of this study was to compare the risk of CSP and hot snare polypectomy (HSP) for such lesions. Data on 0-Ip colorectal polyps ≤10 mm were extracted from a large, pragmatic, randomized trial. Immediate postpolypectomy bleeding (IPPB), defined as the perioperative use of a clip for bleeding, was evaluated through polyp-level analysis. Delayed postpolypectomy bleeding (DPPB), defined as bleeding occurring within 2 weeks postoperatively, was assessed at the patient-level among patients whose polyps were all ≤10 mm, including at least one 0-Ip polyp. A total of 647 0-Ip polyps (CSP: 306; HSP: 341) were included for IPPB analysis and 386 patients (CSP: 192; HSP: 194) for DPPB analysis. CSP was associated with a higher incidence of IPPB (10.8% vs 3.2%, P < 0.001) but no adverse clinical events. The procedure time of all polypectomies was shorter for CSP than for HSP (123.0 ± 117.8 vs 166.0 ± 237.7 seconds, P = 0.003), while the procedure time of polypectomies with IPPB were similar (249.8 ± 140.2 vs 227.4 ± 125.9 seconds, P = 0.64). DPPB was observed in 3 patients (1.5%) in the HSP group, including one patient (0.5%) with severe bleeding, but not in the CSP group. Despite CSP being associated with more IPPB events, it could be timely treated without adverse outcomes. Notably, no delayed bleeding occurred in the CSP group. Our findings support the use of CSP for 0-Ip polyps ≤ 10 mm.

Safety of Cold Snare Polypectomy for Small Colorectal Polyps in Patients Receiving Antithrombotic Therapy

IntroductionEndoscopic removal of colorectal polyps has been shown to reduce the incidence and mortality from colorectal cancer. High quality colonoscopy includes careful polypectomy using appropriate technique to ensure complete and...

Colon polyp retrieval after cold snaring

IntroductionMost polyps are <10 mm in size and a range of polypectomy techniques are available with wide variations in practice. We aimed to examine the techniques employed for removal of...

Objective To compare the efficacy and safety of cold snare polyppectomy (CPS) and hot snare polypectomy (HSP) on 4 to 9 mm colorectal polyps. Methods A total of 365 patients, with 4 to 9 mm polyps, detected in the First Affiliated Hospital of Henan University of Science and Technology from June 2017 to June 2018 were selected and divided into CSP group (192 patients, 267 polyps) and HSP group (173 patients, 225 polyps) by random number table method. And the two groups were treated by CSP and HSP correspondingly. The complete resection rate, specimen retrieval rate, complications, hemoclip applications rate, abdominal discomfort rate, the time cost of average polyppectomy, pathological examination results were compared between the two groups. Results The resection time for one polyp in CSP group was less than that of HSP group (P 0.05). Conclusions CSP, in the comparison to HSP, is an effective and safe method that shortens the polypectomy duration in 4 to 9 mm polyps. Key words: Colonic Polyps; Polypectomy; Cold snare; Hot snare

This study compared the incidence of delayed bleeding following 2 methods of cold snare polypectomy for colorectal polyps in patients taking antithrombotic agents. Patients undergoing cold snare polypectomy for colorectal polyps ≤10 mm without discontinuation of antithrombotic agents were enrolled. This was a retrospective study of a prospectively collected cohort based on a historical comparison of 2 time periods. A traditional cold snare was used between January 2012 and December 2013 and a dedicated cold snare was used between January 2014 and December 2015. Patients' and polyps' characteristics, antithrombotic agents used, the snare used, the number of clips used, and adverse events were documented from a hospital online database. Delayed bleeding was defined as bleeding that required endoscopic treatment within 2 weeks after polypectomy. The submucosal layer of the resected polyps (6 to 10 mm) was histologically examined for the presence of injured arteries. A total of 172 patients having 370 eligible polyps were enrolled; traditional cold snare group, N=100 (212 polyps) and dedicated cold snare group, N=72 (158 polyps). The patients' and polyps' characteristics were similar between the 2 groups. Hemostatic clips were used more often with the traditional than dedicated cold snares [33/100 (33%) vs. 13/72 (18%), P=0.044]. Delayed bleeding following cold snare polypectomy occurred in 1.2% (2/172); 0% (0/72) with dedicated snare versus 2% (2/100) with the traditional snare (P=0.63). The presence of histologically demonstrated injured submucosal arteries with the dedicated cold snare was significantly less than with the traditional cold snare [4.1% (4/98) vs. 16% (17/105), P=0.009]. Colorectal polyps ≤10 mm can be removed without an increase in delayed bleeding using dedicated cold snare polypectomy in patients taking antithrombotic agents.

Su1072 ENDOSCOPIC MANAGEMENT OF RESIDUAL OR RECURRENT NEOPLASIA FOLLOWING PIECEMEAL ENDOSCOPIC MUCOSAL RESECTION IS EFFICACIOUS.

Management of anticoagulants for patients undergoing polypectomy is still controversial. Cold snare polypectomy (CSP) is reported to cause less bleeding than hot snare polypectomy (HSP). To compare outcomes between continuous administration of anticoagulants (CA) with CSP (CA+CSP) and periprocedural heparin bridging (HB) with HSP (HB+HSP) for subcentimeter colorectal polyps. Multicenter, parallel, noninferiority randomized controlled trial. (University Hospital Medical Information Network Clinical Trials Registry: UMIN000019355). 30 Japanese institutions. Patients receiving anticoagulant therapy (warfarin or direct oral anticoagulants) who had at least 1 nonpedunculated subcentimeter colorectal polyp. Patients were randomly assigned to undergo HB+HSP or CA+CSP and followed up 28 days after polypectomy. The primary end point was incidence of polypectomy-related major bleeding (based on the incidence of poorly controlled intraprocedural bleeding or postpolypectomy bleeding requiring endoscopic hemostasis). The prespecified inferiority margin was -5% (CA+CSP vs. HB+HSP). A total of 184 patients were enrolled: 90 in the HB+HSP group, 92 in the CA+CSP group, and 2 who declined to participate after enrollment. The incidence of polypectomy-related major bleeding in the HB+HSP and CA+CSP groups was 12.0% (95% CI, 5.0% to 19.1%) and 4.7% (CI, 0.2% to 9.2%), respectively. The intergroup difference for the primary end point was +7.3% (CI, -1.0% to 15.7%), with a 0.4% lower limit of 2-sided 90% CI, demonstrating the noninferiority of CA+CSP. The mean procedure time for each polyp and the hospitalization period were longer in the HB+HSP than in the CA+CSP group. An open-label trial assessing 2 factors (anticoagulation approach and polypectomy procedure type) simultaneously. Patients having CA+CSP for subcentimeter colorectal polyps who were receiving oral anticoagulants did not have an increased incidence of polypectomy-related major bleeding, and procedure time and hospitalization were shorter than in those having HB+HSP. Japanese Gastroenterological Association.

Most colonic polyps are small, and several polypectomy techniques are available. We aimed to describe the variation in polypectomy techniques employed for the removal of sub-centimeter polyps in relation to polyp characteristics, completeness of histological excision and safety. Prospectively collected data relating to the removal of sub-centimeter polyps over a 3-year period (between January 2010 and December 2012) were retrieved from the English Bowel Cancer Screening Programme. A total of 147,174 sub-centimeter polyps were removed during 62,679 procedures. For pedunculated polyps, hot snare was most common in the left (median 92%, IQR 83.3-97.0%) and right colon (median 75%, IQR 3-92%). For non-pedunculated polyps, cold snare was most common in the right colon (median 24%, IQR 9-47%); whereas hot snare remained most common in the left colon (median 32%, IQR 19-49%). Surgeons were more likely than physicians to use diathermy-assisted techniques (65.6 vs. 56.5%, p<0.001). Twelve (0.03%) bleeding episodes required transfusion with no polypectomy technique dominating and 16 (0.04%) perforations with 81% of polypectomies performed using diathermy-assisted techniques. There was substantial variation between screening centers for the completeness of histological excision. For non-pedunculated polyps, histologically confirmed complete excision was more after EMR (23.4%) compared with other techniques (cold biopsy forceps 17.7%, cold snare 15.1%, hot biopsy forceps 19.1%, hot snare 21.5%). The use of cold techniques and EMR has increased over time, whereas the use of hot biopsy forceps and hot snare has decreased (p<0.001). The removal of sub-centimeter polyps within the BCSP is safe despite wide variations in practice. The use of cold resection techniques and EMR has increased over time. The histological assessment for completeness of excision is limited and should be confirmed endoscopically at the time of polypectomy.