Indications for Cold Polypectomy Stratified by the Colorectal Polyp Size: A Systematic Review and Meta-Analysis

Abstract

Objectives: Cold polypectomy (CP) is widely used because of its safety profile. This systematic review and meta-analysis aimed to clarify the indications for CP based on polyp size. Methods: We searched PubMed and the Cochrane Library for randomized controlled trials that compared cold snare polypectomy (CSP) and other procedures for polyps ! 10 mm. Large-scale prospective observational studies were also searched to assess delayed bleeding rates. The studies were integrated to assess the risk ratio for incomplete resection rates according to polyp size. The Cochrane risk of bias tool was used to evaluate the study bias. The certainty of cumulative evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system. Results: We found 280 articles and reviewed their eligibility. We selected and extracted 12 randomized controlled trials and 3 prospective observational studies. The risk ratio of incomplete resection of polyps ! 10 mm using CSP compared with hot snare polypectomy (HSP) was 1.36 (95% confidence interval [CI], 0.92-2.01). The risk ratio for incomplete removal using CSP compared with cold forceps polypectomy (CFP) was 0.50 (95% CI, 0.31-0.82). For polyps ! 3 mm, the risk ratio of CSP compared with CFP was 1.40 (95% CI, 0.39-4.95). Certainty of cumulative evidence was considered low. No delayed bleeding after CP was reported after the treatment of 3446 polyps. Conclusions: CSP and HSP may result in the same complete resection rates for polyps ! 10 mm. For polyps ! 3 mm, CFP and CSP may have the same resection rates (PROSPERO registration number: CRD 42019122132).

Recurrence rate and lesions characteristics after cold snare polypectomy of high‐grade dysplasia and T1 lesions: A multicenter analysis

“…There have been many reports on the therapeutic results and adverse events associated with CSP. [4][5][6][7][8][9][10][11] However, there have been no reports of HGD and T1 lesions and their follow-up after CSP. In a previous study, we showed that the recurrence rates after CSP for lesions < 10 mm, and lesions 10-14 mm were 1.4% and 5.4%, respectively.…”

“…[4][5][6][7][8][9] The indications for CSP are limited to benign lesions ≤ 10 mm in size, such as adenomas and sessile serrated lesions (SSL), because many studies have shown that the rate of histopathological incomplete resection was higher in CSP than that in standard endoscopic resection with an electrosurgical unit (hot snare polypectomy and endoscopic mucosal resection [EMR]). 6,10,11 Thus, resection of high-grade dysplasia (HGD), which is called as intramucosal cancer in Japan and T1 lesions by CSP is not recommended, and lesions ≥ 10 mm in size are also not recommended due to the risk of malignancy. [10][11][12] Given the above, the indications of CSP should be benign lesions through careful endoscopic observation, if possible using chromoendoscopy, narrow-band imaging (NBI), or blue-laser imaging (BLI), are important before CSP.…”

“…6,10,11 Thus, resection of high-grade dysplasia (HGD), which is called as intramucosal cancer in Japan and T1 lesions by CSP is not recommended, and lesions ≥ 10 mm in size are also not recommended due to the risk of malignancy. [10][11][12] Given the above, the indications of CSP should be benign lesions through careful endoscopic observation, if possible using chromoendoscopy, narrow-band imaging (NBI), or blue-laser imaging (BLI), are important before CSP. [12][13][14][15][16] However, HGD and T1 lesions are sometimes accidentally resected by CSP, even if careful endoscopic observation is performed.…”

Colonoscopy screening and surveillance guidelines

“…From the above, the indication for cold polypectomy is considered for lesions ≤10 mm that are not suspected to be high‐grade dysplasia or invasive cancer endoscopically. It is also desirable to only perform CFP for lesions of ≤3 mm 239 . Most of the above examinations were performed for non‐pedunculated lesions, and the safety and efficacy of cold polypectomy for pedunculated lesions are unknown.…”

Cold snare polypectomy without submucosal injection: safety and efficacy in 615 large serrated lesions

“…Indeed, CSP has been recommended by the American Society for Gastrointestinal Endoscopy (ASGE) 2 and the European Society of Gastrointestinal Endoscopy 3 for the resection of nonpedunculated lesions < 10 mm in size, while the British Society of Gastroenterology has suggested its use for serrated lesions < 1 cm located in the proximal colon 4 . These recommendations were mostly based on the good safety profile of CSP but they have also recently been supported by efficacy studies showing similar rates of complete resection for cold vs. hot snare polypectomy 5 6 . Furthermore, the time and cost requirements of CSP are advantageous compared with those of hot snare polypectomy.…”