Local recurrence of diminutive colorectal polyps after cold forceps polypectomy with jumbo forceps followed by magnified narrow-band imaging: a multicenter prospective study

Background Cold polypectomy has been increasingly used to remove diminutive colorectal polyps. We evaluated the local recurrence rate of diminutive polyps at the 1-year follow-up after cold forceps polypectomy (CFP).

Methods In a prospective, multicenter, observational cohort study, patients with diminutive colorectal polyps ( ≤ 5 mm) were treated by CFP using jumbo forceps followed by magnified narrow-band imaging (NBI). Patients were assessed for local recurrence at 1-year follow-up. Risk factors associated with local recurrence were analyzed using logistic regression analysis.

Results Overall, 955 lesions were resected in 471 patients who completed the 1-year follow-up. The endoscopic complete resection rate was 99.4 %. Immediate and delayed bleeding occurred in 0.8 % and 0.2 % of cases, respectively, with no perforations observed. Local recurrence occurred in 2.1 % of cases at the 1-year follow-up. Univariable analyses indicated that polyps > 3 mm (P < 0.01) and immediate bleeding (P = 0.04) were significantly associated with local recurrence. A trend was observed for patients ≥ 65 years (P = 0.06) and fractional resection (P = 0.09). Multivariable analyses confirmed that lesions > 3 mm were significantly associated with local recurrence (odds ratio 3.4, P = 0.02).

Conclusions CFP with jumbo forceps followed by NBI-magnified observation had a low local recurrence rate and is an acceptable therapeutic option for diminutive colorectal polyps. Although we recommend limiting the use of CFP with jumbo forceps to polyps ≤ 3 mm in size, future comparative studies are needed to make recommendations on cold polypectomy using either forceps or snares as the preferred approach for diminutive polyp resection.

• References

• 1 Shimodate Y, Mizuno M, Takezawa R. et al. Safety of cold polypectomy for small colorectal neoplastic lesions: a prospective cohort study in Japan. Int J Colorectal Dis 2017; 32: 1261-1266
• 2 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
• 3 Jung YS, Park CH, Nam E. et al. Comparative efficacy of cold polypectomy techniques for diminutive colorectal polyps: a systematic review and network meta-analysis. Surg Endosc 2018; 32: 1149-1159
• 4 Winawer SJ, Zauber AG, Ho MN. et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 1993; 329: 1977-1981
• 5 Repici A, Hassan C, Vitetta E. et al. Safety of cold polypectomy for <10 mm polyps at colonoscopy: a prospective multicenter study. Endoscopy 2012; 44: 27-31
• 6 Weston AP, Campbell DR. Diminutive colonic polyps: histopathology, spatial distribution, concomitant significant lesions, and treatment complications. Am J Gastroenterol 1995; 90: 24-28
• 7 Efthymiou M, Taylor AC, Desmond PV. et al. Biopsy forceps is inadequate for the resection of diminutive polyps. Endoscopy 2011; 43: 312-316
• 8 Woods A, Sanowski RA, Wadas DD. et al. Eradication of diminutive polyps: a prospective evaluation of bipolar coagulation versus conventional biopsy removal. Gastrointest Endosc 1989; 35: 536-540
• 9 Draganov PV, Chang MN, Alkhasawneh A. et al. Randomized, controlled trial of standard, large-capacity versus jumbo biopsy forceps for polypectomy of small, sessile, colorectal polyps. Gastrointest Endosc 2012; 75: 118-126
• 10 Raad D, Tripathi P, Cooper G. et al. Role of the cold biopsy technique in diminutive and small colonic polyp removal: a systematic review and meta-analysis. Gastrointest Endosc 2016; 83: 508-515
• 11 Uraoka T, Ramberan H, Matsuda T. et al. Cold polypectomy techniques for diminutive polyps in the colorectum. Dig Endosc 2014; 26 (Suppl. 02) 98-103
• 12 Jung YS, Park JH, Kim HJ. et al. Complete biopsy resection of diminutive polyps. Endoscopy 2013; 45: 1024-1029
• 13 Kanao H, Tanaka S, Oka S. et al. Narrow-band imaging magnification predicts the histology and invasion depth of colorectal tumors. Gastrointest Endosc 2009; 69: 631-636
• 14 Abu Dayyeh BK, Thosani N. ASGE Technology Committee. et al. ASGE Technology Committee systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc 2015; 81: 502.e1-502.e16
• 15 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: 527-32 e1
• 16 Patel SG, Schoenfeld P, Kim HM. et al. Real-time characterization of diminutive colorectal polyp histology using narrow-band imaging: implications for the resect and discard strategy. Gastroenterology 2016; 150: 406-418
• 17 Aslan F, Cekic C, Camci M. et al. What is the most accurate method for the treatment of diminutive colonic polyps? standard versus jumbo forceps polypectomy. Medicine (Baltimore) 2015; 94: e621
• 18 Kim JS, Lee BI, Choi H. et al. Cold snare polypectomy versus cold forceps polypectomy for diminutive and small colorectal polyps: a randomized controlled trial. Gastrointest Endosc 2015; 81: 741-747
• 19 Maruoka D, Arai M, Akizue N. et al. Residual adenoma after cold snare polypectomy for small colorectal adenomas: a prospective clinical study. Endoscopy 2018; 50: 693-700
• 20 Lee HS, Park HW, Lee JS. et al. Treatment outcomes and recurrence following standard cold forceps polypectomy for diminutive polyps. Surg Endosc 2017; 31: 159-169
• 21 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 2017; DOI: 10.1136/gutjnl-2017-314215. pii: gutjnl-2017-314215
• 22 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon. Gastrointest Endosc 2003; 58: S3-S43
• 23 Sugai T, Habano W, Uesugi N. et al. Molecular validation of the modified Vienna classification of colorectal tumors. J Mol Diagn 2002; 4: 191-200
• 24 Ellis K, Marquis S, Katon R. Efficacy of hot biopsy forceps, cold micro-snare and micro-snare with cautery techniques in the removal of diminutive colonic polyps. Gastrointest Endosc 1997; 45: AB107
• 25 Oka S, Tanaka S, Kanao H. et al. Current status in the occurrence of postoperative bleeding, perforation and residual/local recurrence during colonoscopic treatment in Japan. Dig Endosc 2010; 22: 376-380
• 26 Singh N, Harrison M, Rex DK. A survey of colonoscopic polypectomy practices among clinical gastroenterologists. Gastrointest Endosc 2004; 60: 414-418
• 27 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
• 28 Lee J. Resection of diminutive and small colorectal polyps: what is the optimal technique?. Clin Endosc 2016; 49: 355-358
• 29 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
• 30 Chung YW, Han DS, Park KH. et al. Patient factors predictive of inadequate bowel preparation using polyethylene glycol: a prospective study in Korea. J Clin Gastroenterol 2009; 43: 448-452
• 31 Ikematsu H, Matsuda T, Osera S. et al. Usefulness of narrow-band imaging with dual-focus magnification for differential diagnosis of small colorectal polyps. Surg Endosc 2015; 29: 844-850
• 32 Singh R, Jayanna M, Navadgi S. et al. Narrow-band imaging with dual focus magnification in differentiating colorectal neoplasia. Dig Endosc 2013; 25 (Suppl. 02) 16-20