Impact of submucosal saline solution injection for cold snare polypectomy of small colorectal polyps: a randomized controlled study

Shimodate, Yuichi; Itakura, Junya; Takayama, Hiromitsu; Ueno, Masashi; Takezawa, Rio; Nishimura, Naoyuki; Mouri, Hirokazu; Sunami, Tomohiko; Hirai, Ryosuke; Yamamoto, Shumpei; Miyake, Muneaki; Matsueda, Kazuhiro; Yamamoto, Yoshiharu; Mizuno, Motowo

doi:10.1016/j.gie.2020.05.039

Cited by 26 publications

(45 citation statements)

References 17 publications

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“…20 A previous study showed that submucosal injection did not improve the resection depth of CSP. 21 The median resection depth of the submucosal layer was 200 mm in both CSP with submucosal injection and conventional CSP groups. 21 On the other hand, another study reported that the mean resection depth for HSP was 933 mm, which was significantly greater than the mean of 51 mm for CSP (P < 0.001).…”

Section: Discussionmentioning

confidence: 91%

“…21 The median resection depth of the submucosal layer was 200 mm in both CSP with submucosal injection and conventional CSP groups. 21 On the other hand, another study reported that the mean resection depth for HSP was 933 mm, which was significantly greater than the mean of 51 mm for CSP (P < 0.001). 22 Electrocautery provides extra power in cutting rather than tearing through the mucosa and MM tissues.…”

Section: Discussionmentioning

confidence: 91%

“…The European Society of Gastrointestinal Endoscopy recommends submucosal injection prior to hot snare polypectomy (HSP) for removal of sessile polyps 10–19 mm, but this is only in order to reduce the risk of deep thermal injury resulting in perforation 20 . A previous study showed that submucosal injection did not improve the resection depth of CSP 21 . The median resection depth of the submucosal layer was 200 mm in both CSP with submucosal injection and conventional CSP groups 21 .…”

Section: Discussionmentioning

confidence: 99%

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Depth of the cutting plane with underwater and conventional endoscopic mucosal resection: Post‐hoc analysis of a randomized study

Matsueda

Takeuchi

Kitamura

et al. 2022

J of Gastro and Hepatol

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Background and Aim:A multicenter randomized controlled trial reported a better R0 resection rate for intermediate-sized (10-20 mm) colorectal polyps with underwater endoscopic mucosal resection (UEMR) than conventional endoscopic mucosal resection (CEMR). To clarify whether UEMR removes enough submucosal tissue in the removal of unpredictable invasive cancers, we investigated the cutting plane depth with UEMR versus CEMR. Methods: This was a post-hoc analysis of a randomized controlled trial in which 210 intermediate-sized colorectal polyps were removed in five Japanese hospitals. One pathologist and two gastroenterologists independently reviewed all resected specimens and measured the cutting plane depth. The cutting plane depth was evaluated as (i) maximum depth of submucosal layer and (ii) mean depth of submucosal layer, calculated using a virtual pathology system. Results: We identified 168 appropriate specimens for the evaluation of the cutting plane depth, resected by UEMR (n = 88) and CEMR (n = 80). The median resection depth was not significantly different between UEMR and CEMR specimens, regardless of the measurement method ([i] 1317 vs 1290 μm, P = 0.52; [ii] 619 vs 545 μm, P = 0.32). All specimens in the UEMR and CEMR groups contained substantial submucosa and no muscularis propria. Conclusions: The cutting plane depth with UEMR was comparable with that with CEMR. UEMR can be a viable alternative method that adequately resects the submucosal layer for the histopathological assessment of unpredictable submucosal invasive cancers.

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Section: Discussionmentioning

confidence: 91%

Section: Discussionmentioning

confidence: 91%

Section: Discussionmentioning

confidence: 99%

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Depth of the cutting plane with underwater and conventional endoscopic mucosal resection: Post‐hoc analysis of a randomized study

Matsueda

Takeuchi

Kitamura

et al. 2022

J of Gastro and Hepatol

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“…Other factors, such as SI, may also play a role in completeness of resection. A recent RCT demonstrated lower complete resection rates related to the use of SI in cold snare resection of small lesions [26].…”

Section: Discussionmentioning

confidence: 99%

Safety and effectiveness of underwater cold snare resection without submucosal injection of large non-pedunculated colorectal lesions

et al. 2022

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Background and study aims Adverse events are uncommon with cold snaring, but cold techniques are generally reserved for lesions ≤ 9 mm out of concern for incomplete resection or inability to mechanically resect larger lesions. In a non-distended, water-filled lumen, colorectal lesions are not stretched, enabling capture and en bloc resection of large lesions. We assessed the effectiveness and safety of underwater cold snare resection (UCSR) without submucosal injection (SI) of ≥ 10 mm non-pedunculated, non-bulky (≤ 5 mm elevation) lesions with small, thin wire snares. Patients and methods Retrospective analysis of an observational cohort of lesions removed by UCSR during colonoscopy. A single endoscopist performed procedures using a small thin wire (9-mm diameter) cold or (10-mm diameter) hybrid snare. Results Fifty-three lesions (mean 15.8 mm [SD 6.9]; range 10–35 mm) were removed by UCSR from 44 patients. Compared to a historical cohort, significantly more lesions were resected en bloc by UCSR (84.9 % [45/53]; P = 0.04) compared to conventional endoscopic mucosal resection (EMR) (64.0 % [32/50]). Results were driven by high en bloc resection rates for 10– to 19-mm lesions (97.3 % [36/37]; P = 0.01). Multiple logistic regression analysis adjusted for potential confounders showed en bloc resection was significantly associated with UCSR compared to conventional EMR (OR 3.47, P = 0.027). Omission of SI and forgoing prophylactic clipping of post-resection sites did not result in adverse outcomes. Conclusions UCSR of ≥ 10 mm non-pedunculated, non-bulky colorectal lesions is feasible with high en bloc resection rates without adverse outcomes. Omission of SI and prophylactic clipping decreased resource utilization with economic benefits. UCSR deserves further evaluation in a prospective comparative study.

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“…On the other hand, some other articles that were not included in the current search have reported that submucosal injection does not improve the CRR with cold and hot procedures. 21,22 Thus, the current evidence indicates that electrocautery does not affect the CRR; however, whether submucosal injection can improve the CRR or not is controversial.…”

Section: Completeness Of Resection For Cold and Hot Proceduresmentioning

confidence: 99%

Safety and efficacy of cold versus hot snare polypectomy including colorectal polyps ≥1 cm in size

Takeuchi

Shichijo

Kawakami

et al. 2021

Digestive Endoscopy

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Cold snare polypectomy (CSP; polypectomy without electrocautery) has spread rapidly worldwide during the past decade in what has been called "Cold Revolution". We performed a PubMed literature search for studies investigating CSP outcomes for colorectal polyps. Five randomized controlled trials (RCTs) assessed the complete resection rates (CRRs). The CRRs were similar regardless of the presence or absence of electrocautery, and the efficacy of submucosal injection for better CRRs is still controversial. Eight RCTs assessed the adverse events. The incidence of intraprocedural bleeding with cold procedures was comparable to or higher than that of hot procedures. The incidences of delayed bleeding were comparable to or lower with cold procedures, especially in patients taking anticoagulants. Fifteen studies have been reported on CSP for large (≥1 cm) colorectal polyps (10 retrospective studies, four prospective single-arm studies, and one prospective RCT). These studies reported that the safe cold procedures (a low intra-and post-procedural bleeding rate without perforation) could be implemented for lesions ≥1 cm. However, considering the incision depth of CSP and the local recurrence rate based on the current evidence, only large sessile serrated lesions (SSLs) can be candidates for cold procedures, and large adenomas should not be candidates for this procedure. Based on the current evidence, CSP seems to be the appropriate standard procedure for sub-centimeter colorectal low-grade adenomas due to its safety and simplicity. Thus, large SSLs can be candidates for cold procedures; however, careful inspection and further prospective studies are warranted to confirm the procedure's clinical relevance.

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Impact of submucosal saline solution injection for cold snare polypectomy of small colorectal polyps: a randomized controlled study

Cited by 26 publications

References 17 publications

Depth of the cutting plane with underwater and conventional endoscopic mucosal resection: Post‐hoc analysis of a randomized study

Depth of the cutting plane with underwater and conventional endoscopic mucosal resection: Post‐hoc analysis of a randomized study

Safety and effectiveness of underwater cold snare resection without submucosal injection of large non-pedunculated colorectal lesions

Safety and efficacy of cold versus hot snare polypectomy including colorectal polyps ≥1 cm in size

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