Complete polyp resection with cold snare versus hot snare polypectomy for polyps of 4–9 mm: a randomized controlled trial

Abstract

Background and study aims: Endoscopic screening with polypectomy reduces colorectal cancer (CRC) incidence. Incomplete polyp removal may attenuate the effect of screening. This randomized trial compared cold snare polypectomy (CSP) with hot snare polypectomy (HSP) regarding complete polyp resection. Patients and methods: We included patients ≥ 40 years at 8 hospitals in 4 countries who had at least one 4-9 mm non-pedunculated polyp detected at colonoscopy. Patients were randomized 1:1 to CSP or HSP. Biopsies from the resection margins were obtained systematically after polypectomy in both groups. We hypothesized that CSP would be non-inferior to HSP with a non-inferiority margin of 5%. Logistic regression models were fitted to identify factors explaining incomplete resection. Results: In total, 425 patients, with 608 polyps were randomized to either CSP or HSP. Of 318 polyps removed by CSP and 283 polyps removed by HSP, 34 (10.7%) and 21 (7.4%) were incompletely resected, respectively, with an adjusted risk difference of 3.2% (95% CI -1.4 – 7.8). There was no difference between the groups in terms of post-polypectomy bleeding, perforation, or abdominal pain. Independent risk factors for incomplete removal were serrated, odds ratio (OR) 3.96, (95% CI 1.63-9.66) and hyperplastic histology, OR 2.52 (95% CI 1.30-4.86)) in adjusted analyses. Conclusion: In this randomized trial, non-inferiority for cold snare polypectomy could not be demonstrated. Polyps with serrated histology are more prone to incomplete resection compared to adenomas. Cold snare polypectomy for small polyps can be used safely in routine colonoscopy practise.

Are we ready for the cold snare revolution?

“…Third, the IRR was strikingly different for serrated polyps (26 %) compared with adenomas (16 %), even if such differences were not statistically significant. This difference has also been reported by others 6 7 . Finally, in this study, as in numerous other studies of colonoscopy quality, the inter-endoscopist variation is large.…”

Clip-assisted endoloop ligation of the mucosal defect after resection of colorectal polyps decreased postprocedural delayed bleeding

“…Although some data 7,19,20 presented in the literature showed no definitive advantages of clipping after EMR for preventing PDB, especially for removal of 6-9 mm polyps. Lots of studies 5,[21][22][23][24][25] showed that clip closure after EMR of large colorectal lesions is cost effective, especially in patients with a high risk of bleeding.…”

Different endoscopic treatments for small colorectal polyps: A systematic review, pair-wise, and network meta-analysis

“…A flow 10.3389/fmed.2023.1154411 chart of the trial selection process is shown in Figure 1. Fourteen articles compared HSP with CSP, (15,16,21,(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35) three articles compared HSP to EMR, (31, 36, 37) three articles compared CSP to CS-EMR, (31,38,39) two articles compared CSP to EMR, (31, 40) two articles compared CSP to UCSP, (41,42) one article compared CS-EMR to EMR, (43) one article compared UEMR to EMR, (44) and one article compared APC to HSP and CSP (33). All studies were published after 2010, and nine studies were multicenter studies.…”

“…Fourteen articles were included in the meta-analysis comparing CSP with HSP for small polyps, (15,16,21,(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35). Seventeen articles were included in the network metaanalysis for 4-10 mm non-pedunculated polyps (27)(28)(29)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44). The characteristics of the included studies are summarized in Table 1.…”