Hot snare vs. cold snare polypectomy for endoscopic removal of 4 – 10 mm colorectal polyps during colonoscopy: a systematic review and meta-analysis of randomized controlled studies

Abstract

Introduction In recent years, cold snare polypectomy (CSP) has increasingly been used over hot snare polypectomy (HSP) for the removal of colorectal polyps (4 – 10 mm in size). However, the optimal technique (CSP vs. HSP), in terms of complete polyp resection and complications, is uncertain. Our aim was to compare incomplete resection rate (IRR) of polyps and complications using CSP vs. HSP.

Methods Randomized controlled studies (RCTs) comparing CSP and HSP for removal of 4 – 10 mm colorectal polyps were considered. Studies were included in the analysis if they obtained biopsy specimens from the resection margin to confirm the absence of residual tissue and reported complications. IRR and complication rate were the outcome measures. Pooled rates were reported as Odds Ratios (OR) or risk difference with 95 % Confidence Interval (CI).

Results In total, three RCTs were included in the final analysis. A total of 1051 patients with 1485 polyps were randomized to either HSP group (n = 741 polyps) or CSP group (n = 744 polyps). The overall IRR did not differ between the two groups (HSP vs. CSP: 2.4 % vs. 4.7 %; OR 0.51, 95 %CI 0.13 – 1.99, P = 0.33, I ² = 73 %). The HSP group had a lower rate of overall complications compared to the CSP group (3.7 % vs. 6.6 %; OR 0.53, 95 % CI 0.3 – 0.94, P = 0.03, I ² = 0 %). Polyp retrieval rates were not different between the two groups (99 % vs. 98.1 %).

Conclusion Our results suggest that HSP and CSP techniques can be effectively used for the complete removal of 4 – 10 mm colorectal polyps; however, HSP has a lower incidence of overall complications.

• References

• 1 American Cancer Society. Cancer Facts & Figures 2017. Available from: https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2017/cancer-facts-and-figures-2017.pdf [cited 21 December 2017]
• 2 Winawer S, Zauber A, Ho M. et al. Prevention of colorectal cancer by colonoscopic polypectomy. NEJM 1993; 329: 1977-1981
• 3 Zauber A, Winawer S, O’Brien M. et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. NEJM 2012; 366: 687-696
• 4 Pohl H, Srivastava A, Bensen S. et al. Incomplete polyp resection during colonoscopy – results of the Complete Adenoma Resection (CARE) study. Gastroenterology 2013; 144: 74-80.e1
• 5 Hassan C, Pickhardt P, Kim D. et al. Systematic review: distribution of advanced neoplasia according to polyp size at screening colonoscopy. Aliment Pharmacol Ther 2010; 31: 210-217
• 6 Gómez V, Badillo R, Crook J. et al. Diminutive colorectal polyp resection comparing hot and cold snare and cold biopsy forceps polypectomy. Results of a pilot randomized, single-center study (with videos). Endosc Int Open 2014; 03: E76-E80
• 7 Metz A, Moss A, Mcleod D. et al. A blinded comparison of the safety and efficacy of hot biopsy forceps electrocauterization and conventional snare polypectomy for diminutive colonic polypectomy in a porcine model. Gastrointest Endosc 2013; 77: 484-490
• 8 Yamashina T, Fukuhara M, Maruo T. et al. Cold snare polypectomy reduced delayed postpolypectomy bleeding compared with conventional hot polypectomy: a propensity score-matching analysis. Endosc Int Open 2017; 05: E587-E594
• 9 Piraka C, Saeed A, Waljee A. et al. Cold snare polypectomy for non-pedunculated colon polyps greater than 1 cm. Endosc Int Open 2017; 05: E184-E189
• 10 Repici A, Hassan C, Vitetta E. et al. Safety of cold polypectomy for < 10 mm polyps at colonoscopy: a prospective multicenter study. Endoscopy 2011; 44: 27-31
• 11 Chukmaitov A, Bradley C, Dahman B. et al. Polypectomy techniques, endoscopist characteristics, and serious gastrointestinal adverse events. J Surg Oncol 2014; 110: 207-213
• 12 Aslan F, Camci M, Alper E. et al. Cold snare polypectomy versus hot snare polypectomy in endoscopic treatment of small polyps. Turk J Gastroenterol 2014; 25: 279-283
• 13 Ichise Y, Horiuchi A, Nakayama Y. et al. Prospective randomized comparison of cold snare polypectomy and conventional polypectomy for small colorectal polyps. Digestion 2011; 84: 78-81
• 14 Horiuchi A, Nakayama Y. 587g: Prospective randomized comparison of cold snare polypectomy and conventional polypectomy. Gastrointest Endosc 2010; 71: AB127
• 15 Paspatis G, Tribonias G, Konstantinidis K. et al. A prospective randomized comparison of cold vs hot snare polypectomy in the occurrence of postpolypectomy bleeding in small colonic polyps. Colorectal Dis 2011; 13: e345-e348
• 16 Efthymiou M, Taylor A, Desmond P. et al. Biopsy forceps is inadequate for the resection of diminutive polyps. Endoscopy 2011; 43: 312-316
• 17 Fujiya M, Sato H, Ueno N. et al. Efficacy and adverse events of cold vs hot polypectomy: A meta-analysis. World J Gastroenterol 2016; 22: 5436
• 18 European Society of Gastrointestinal Endoscopy (ESGE). Colorectal polypectomy and endoscopic mucosal resection (EMR). 2018 Available from: http://www.esge.com/colorectal-polypectomy-and-endoscopic-mucosal-resection-emr-esge.html [cited 5 January 2018]
• 19 Kawamura T, Takeuchi Y, Asai S. et al. A comparison of the resection rate for cold and hot snare polypectomy for 4–9 mm colorectal polyps: a multicentre randomised controlled trial (CRESCENT study). Gut 2018; 67: 1950-1957
• 20 Papastergiou V, Paraskeva K, Fragaki M. et al. Cold versus hot endoscopic mucosal resection for nonpedunculated colorectal polyps sized 6–10 mm: a randomized trial. Endoscopy 2018; 50: 403-411
• 21 Zhang Q, Gao P, Han B. et al. Polypectomy for complete endoscopic resection of small colorectal polyps. Gastrointest Endosc 2018; 87: 733-740
• 22 Endoscopic Classification Review Group. Update on the Paris Classification of superficial neoplastic lesions in the digestive tract. Endoscopy 2005; 37: 570-578
• 23 Schlemper R. The Vienna classification of gastrointestinal epithelial neoplasia. Gut 2000; 47: 251-255
• 24 Shuster J. Review: Cochrane Handbook for Systematic Reviews for Interventions, Version 5.1.0, published 3/2011. Julian P.T. Higgins and Sally Green, Editors. Res Synth Methods 2011; 2: 126-130
• 25 Higgins J, Thompson SG, Deeks JJ. et al. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557-560
• 26 Liu S, Ho S, Krinsky M. Quality of polyp resection during colonoscopy: are we achieving polyp clearance?. Dig Dis Sci 2012; 57: 1786-1791
• 27 Levin T, Zhao W, Conell C. et al. Complications of colonoscopy in an integrated health care delivery system. Ann Intern Med 2006; 145: 880
• 28 Sorbi D, Norton I, Conio M. et al. Postpolypectomy lower GI bleeding: Descriptive analysis. Gastrointest Endosc 2000; 51: 690-696
• 29 Park S, Lee M, Jeong S. et al. Prospective analysis of minor adverse events after colon polypectomy. Dig Dis Sci 2017; 62: 2113-2119
• 30 Luigiano C, Consolo P, Scaffidi M. et al. Endoscopic mucosal resection for large and giant sessile and flat colorectal polyps: a single-center experience with long-term follow-up. Endoscopy 2009; 41: 829-835
• 31 Doniec M, Löhnert M, Schniewind B. et al. Endoscopic removal of large colorectal polyps. Dis Colon Rectum 2003; 46: 340-348
• 32 Heldwein W, Dollhopf M, Rösch T. et al. The Munich Polypectomy Study (MUPS): Prospective analysis of complications and risk factors in 4000 colonic snare polypectomies. Endoscopy 2005; 37: 1116-1122
• 33 Matsuura N, Takeuchi Y, Yamashina T. et al. Incomplete resection rate of cold snare polypectomy: a prospective single-arm observational study. Endoscopy 2017; 49: 251-257