“Cold” polypectomy for colorectal polyps: prospective randomized trial

Abstract

Background: endoscopic electroexcision is the standard technique for the removal of colorectal polyps. However, it is associated with the postoperative morbidity. In order to reduce the incidence of complications, “cold” excision seems to be an alternative option.Aim: to improve the results of endoscopic treatment for patients with colorectal polyps.Patients and methods: from September 2019 to September 2020, 160 patients ≥ 18 years old (80 in each group), who underwent endoscopic removal of colorectal polyps ≤ 10 mm in size by cold excision (132 lesions) and traditional polypectomy (129 lesions), were included in a prospective randomized trial. All removed specimens were studied histologically with an assessment of the resection margins (R0/R1). The analysis of the postoperative complications after endoscopic polypectomy and the incidence of Rx resection after removal of polyps by both techniques was done.Results: the compared groups were homogenous in the number of patients, gender, age, and comobridities. There were no significant differences in the number of removed polyps, their site and the type according to endoscopic classifications. The operation time was significantly higher in the conventional polypectomy group compared with the “cold” one (p = 0.0001). There were no significant differences in the intraoperative complications rate between the two groups (p = 0.06). There were no postoperative complications in the “cold” group. In the control group postoperative complications occurred after 12 out of 129 polyps removal (p = 0.001). The univariate analysis showed that a risk factor for the development of postoperative complications after conventional polypectomy is the lack of submucosal lifting (OR: 15.3, 95% CI: 1.9-125.6, p = 0.01). Histopathology of the removed specimens showed that in both groups most of the procedures were considered as R0 resections (54% in the main group, 56.4% in the control group, p = 0.8). The polyp size ≤ 4 mm identified as a risk factor for R1, Rx resection (OR: 2.4, 95% CI: 1.3–4.7, p = 0.007).Conclusion: “cold” polypectomy is an effective and safe method and may be recommended as an alternative technique for the removal of non-pedunculated colorectal polyps ≤ 10 mm.

Cold Versus Hot Snare Polypectomy for Colorectal Polyps

“…48 Hence, the recommendation was to use the electrosurgical setting preferred by the endoscopist. 48 In our meta-analysis, 6 trials used endocut, 21,23,27,28,40,43 4 trials used forced coagulation, 4,16,17,22 3 trials used both techniques based on endoscopist's preference, 8,14,24 and 5 trials did not report the electrocautery technique. [18][19][20]29,42 Polyp retrieval for complete histologic evaluation is essential to determine the necessity of additional treatment and the appropriate colonoscopic follow-up interval.…”

“…Moreover, in the trials that used the negative biopsy approach, the number of biopsies taken varied, and we can assume that taking more biopsies increased the ability to assess incomplete resection. 19 Second, the submucosal injection was used in 9 trials either in the EMR groups only or it was permitted on the endoscopist's preference 4,14,17,18,20,28,29,40,43 (Table 2). Third, the resection area and degree of cauterization vary among endoscopists.…”

“…4 Therefore, electrocautery with HSP can be considered a direct predisposing factor to postpolypectomy syndrome (PPCS), and our pooled analysis showed a significant association between HSP and PPCS, supporting this hypothesis; however, only 2 trials reported PCSS. 17,22 The use of anticoagulants during polypectomy can also be considered a predisposing factor for PPCS and delayed bleeding. 17 Thus, CSP can be considered the optimal approach in patients on anticoagulants, especially high-risk patients who cannot stop it.…”

“…17,22 The use of anticoagulants during polypectomy can also be considered a predisposing factor for PPCS and delayed bleeding. 17 Thus, CSP can be considered the optimal approach in patients on anticoagulants, especially high-risk patients who cannot stop it. 18 Moreover, abdominal pain was also significantly associated with HSP.…”

“…The included studies showed a low risk in random sequence generation, except for 3 studies (Ichise et al, 42 Ito et al, 21 and Zhang et al, 40 ) which showed an unclearROB. Moreover, the included studies showed a low risk of allocation concealment, except for 3 studies (Gomez et al, 4 Suzuki et al, 27 and Toporkova et al 17 ) showing unclear risk, and Ito et al 21 showing a high ROB. Furthermore, all the included trials showed a high risk of performance and detection biases; operating endoscopists cannot be blinded; however, this can substantially affect the findings as they can be more careful with the HSP arm, trying to avoid its well-known complications.…”