Risk of delayed bleeding before and after implementation of cold snare polypectomy in a screening colonoscopy setting

Abstract

Background and study aims Cold snare polypectomy (CSP) is considered to be effective in reducing risk of delayed bleeding but randomized trials fail to support this owing to the small sample size. The current study aimed to compare risk of delayed bleeding before and after implementation of CSP in a screening colonoscopy setting.

Patients and methods This study retrospectively analyzed a prospectively maintained screening colonoscopy database in a university hospital in Taiwan. We compared the rate of delayed bleeding before and after implementation within similar periods (18 months and 15 months) and the respective number of polypectomies (1,304 and 1,255) performed to remove small and diminutive polyps. The main outcome measurement was delayed bleeding within the two periods. Multivariate analysis was performed to adjust for major confounders.

Results A total of 1,304 and 1,225 subjects received hot snare polypectomy (HSP) and CSP in two separate periods, respectively. Compared with the HSP, the CSP had a lower rate of delayed bleeding (0.1 % vs. 1.1 %, P < 0.001), severe bleeding (0 % vs. 0.7 %, P < 0.01), need for second-look colonoscopy (0 % vs. 0.8 %, P < 0.01), and emergency service visits (0.1 % vs. 1.0 %, P < 0.01). Total procedure time (12.60 ± 11.45 vs. 16.48 ± 14.27 min/person, P < 0.01) and duration of hospital stay (1.18 ± 0.50 vs. 1.53 ± 5.78 hour/person, P < 0.03) were also shorter after CSP implementation. Multivariate analysis showed that HSP was an independent risk factor for delayed bleeding after adjusting for age, gender, and number of polyps (adjusted odds ratio 14.4;95 % confidence interval = 1.88 – 110.6).

Conclusion Implementation of CSP significantly reduces risk of delayed bleeding associated with removing small and diminutive polyps in screening colonoscopy.

• References

• 1 Gupta N, Bansal A, Rao D. et al. Prevalence of advanced histological features in diminutive and small colon polyps. Gastrointest Endosc 2012; 75: 1022-1030
• 2 Lorenzo-Zuniga V, Boix J, Moreno-de-Vega V. et al. Microperforation of the colon: animal model in rats to reproduce mucosal thermal damage. J Surg Res 2014; 188: 415-418
• 3 Tappero G, Gaia E, De Giuli P. et al. Cold snare excision of small colorectal polyps. Gastrointest Endosc 1992; 38: 310-313
• 4 Horiuchi A, Nakayama Y, Kajiyama M. et al. Removal of small colorectal polyps in anticoagulated patients: a prospective randomized comparison of cold snare and conventional polypectomy. Gastrointest Endosc 2014; 79: 417-423
• 5 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297
• 6 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; 5: E587-E594
• 7 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: 5436-5444
• 8 Horiuchi A, Hosoi K, Kajiyama M. et al. Prospective, randomized comparison of 2 methods of cold snare polypectomy for small colorectal polyps. Gastrointest Endosc 2015; 82: 686-692
• 9 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
• 10 Paspatis GA, 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: e345-348
• 11 Gomez V, Badillo RJ, Crook JE. 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 2015; 3: E76-E80
• 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 Charlson ME, Pompei P, Ales KL. et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40: 373-383
• 14 von Elm E, Altman DG, Egger M. et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med 2007; 147: 573-577
• 15 Chang LC, Wu MS, Tu CH. et al. Metabolic syndrome and smoking may justify earlier colorectal cancer screening in men. Gastrointest Endosc 2014; 79: 961-969
• 16 Chang LC, Shun CT, Hsu WF. et al. Fecal immunochemical test detects sessile serrated adenomas and polyps with a low level of sensitivity. Clin Gastroenterol Hepatol 2017; 15: 872-879 e871
• 17 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: S3-43
• 18 Snover DC. BRWea. Serrated polyps of the colon and rectum and serrated polyposis. Bosman FT, Carneiro F, Hruban RH. et al. WHO Classification of Tumours of the Digestive System, Fourth Edition. Lyon: IARC Press; 2010: 160-165
• 19 Repici A, Hassan C, Vitetta E. et al. Safety of cold polypectomy for <10mm polyps at colonoscopy: a prospective multicenter study. Endoscopy 2012; 44: 27-31
• 20 Warren JL, Klabunde CN, Mariotto AB. et al. Adverse events after outpatient colonoscopy in the Medicare population. Ann Intern Med 2009; 150: 849-857, W152
• 21 Rex DK, Lewis BS, Waye JD. Colonoscopy and endoscopic therapy for delayed post-polypectomy hemorrhage. Gastrointest Endosc 1992; 38: 127-129
• 22 Rutter MD, Nickerson C, Rees CJ. et al. Risk factors for adverse events related to polypectomy in the English Bowel Cancer Screening Programme. Endoscopy 2014; 46: 90-97
• 23 Van Gossum A, Cozzoli A, Adler M. et al. Colonoscopic snare polypectomy: analysis of 1485 resections comparing two types of current. Gastrointest Endosc 1992; 38: 472-475
• 24 Sorbi D, Norton I, Conio M. et al. Postpolypectomy lower GI bleeding: descriptive analysis. Gastrointest Endosc 2000; 51: 690-696
• 25 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
• 26 Lee CK, Shim JJ, Jang JY. Cold snare polypectomy vs. Cold forceps polypectomy using double-biopsy technique for removal of diminutive colorectal polyps: a prospective randomized study. Am J Gastroenterol 2013; 108: 1593-1600
• 27 Park SK, Ko BM, Han JP. et al. A prospective randomized comparative study of cold forceps polypectomy by using narrow-band imaging endoscopy versus cold snare polypectomy in patients with diminutive colorectal polyps. Gastrointest Endosc 2016; 83: 527-532 e521
• 28 Maruoka D, Arai M, Akizue N. et al. Residual adenoma after cold snare polypectomy for small colorectal adenomas: a prospective clinical study. Endoscopy 2018; [Epub ahead of print]
• 29 Din S, Ball AJ, Riley SA. et al. Cold snare polypectomy: does snare type influence outcomes?. Dig Endosc 2015; 27: 603-608