Cold snare defect protrusion and incomplete polyp resection after forced cold snare polypectomy: a prospective observational study

Abstract

Background Cold snare defect protrusions (CSDPs) that occur after cold snare polypectomy (CSP) are considered indicators of incomplete polyp resection (IPR). We have sometimes experienced difficulty resecting polyps with snaring alone; in such cases, a forcible pull on the snare by the endoscopist is necessary. We call this procedure “forced CSP (FCSP).” However, no previous studies have evaluated this procedure.

Methods This was a prospective observational study. From November 2020 to June 2021, the frequency, safety, and validity of FCSP were evaluated at our hospital. We distinguished CSP with snaring alone performed by the assistant as conventional CSP, and CSP requiring a forcible pull on the snare by the endoscopist as FCSP.

Results Of 1315 polyps removed, 105 underwent FCSP (8%). The perforation rate was 0% in both groups. The rate of CSDP after the procedure was 96.2% (101/105) with FCSP and 6.4% (77/1210) with conventional CSP (P<0.001). The rate of IPR was 12.5% (13/104) with FCSP and 6.2% (75/1208) with conventional CSP (P=0.02). Multivariable analysis identified polyps located in the cecum (risk ratio [RR], 1.13; 95%CI 1.050–1.179; P=0.003) and polyps ≥6mm in diameter (RR, 2.37; 95%CI 2.146–2.542; P<0.001) as independent risk factors for FCSP.

Conclusions FCSP was performed on 105 polyps (8%) in this study. FCSP may be associated with the occurrence of CSDP and IPR. Further studies are necessary to confirm our results.

Publication History

Received: 05 January 2023

Accepted after revision: 28 September 2023

Accepted Manuscript online:
28 September 2023

Article published online:
10 November 2023

• References

• 1 Shaukat A, Mongin SJ, Geisser MS. et al. Long-term mortality after screening for colorectal cancer. N Engl J Med 2013; 369: 1106-1114 DOI: 10.1056/NEJMoa1300720. (PMID: 24047060)
• 2 Zauber AG, Winawer SJ, O’Brien MJ. et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696 DOI: 10.1056/NEJMoa1100370. (PMID: 22356322)
• 3 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 DOI: 10.1056/NEJM199312303292701. (PMID: 8247072)
• 4 Levin TR, Zhao W, Conell C. et al. Complications of colonoscopy in an integrated health care delivery system. Ann Intern Med 2006; 145: 880-886 DOI: 10.7326/0003-4819-145-12-200612190-00004. (PMID: 17179057)
• 5 Watabe H, Yamaji Y, Okamoto M. et al. Risk assessment for delayed hemorrhagic complication of colonic polypectomy: polyp-related factors and patient-related factors. Gastrointest Endosc 2006; 64: 73-78 DOI: 10.1016/j.gie.2006.02.054. (PMID: 16813806)
• 6 Sonnenberg A. Management of delayed postpolypectomy bleeding: a decision analysis. Am J Gastroenterol 2012; 107: 339-342 DOI: 10.1038/ajg.2011.426. (PMID: 22388016)
• 7 Takeuchi Y, Yamashina T, Matsuura N. et al. Feasibility of cold snare polypectomy in Japan: a pilot study. World J Gastrointest Endosc 2015; 7: 1250-1256 DOI: 10.4253/wjge.v7.i17.1250. (PMID: 26634041)
• 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; 5: E587-594
• 9 Arimoto J, Chiba H, Ashikari K. et al. Safety of cold snare polypectomy in patients receiving treatment with antithrombotic agents. Dig Dis Sci 2019; 64: 3247-3255
• 10 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 DOI: 10.1159/000323959. (PMID: 21494037)
• 11 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 DOI: 10.3748/wjg.v22.i23.5436. (PMID: 27340361)
• 12 Ogasawara N, Takayama M, Ono S. et al. A case of colonic stenosis caused by cold snare polypectomy for the removal of a colonic polyp. Clin J Gastroenterol 2017; 10: 415-419 DOI: 10.1007/s12328-017-0765-9. (PMID: 28744763)
• 13 Sanchez JR, Alonso MS, Urquiza MP. The “bubble sign”: a novel way to detect a perforation after cold snare polypectomy. Endoscopy 2019; 51: 796-797
• 14 Tutticci N, Burgess NG, Pellise M. et al. Characterization and significance of protrusions in the mucosal defect after cold snare polypectomy. Gastrointest Endosc 2015; 82: 523-528 DOI: 10.1016/j.gie.2015.01.051. (PMID: 25910666)
• 15 Shichijo S, Takeuchi Y, Kitamura M. et al. Does cold snare polypectomy completely resect the mucosal layer? A prospective single-center observational trial. J Gastroenterol Hepatol 2020; 35: 241-248
• 16 Ishii T, Harada T, Tanuma T. et al. Histopathologic features and fragmentation of polyps with cold snare defect protrusions. Gastrointest Endosc 2021; 93: 952-959
• 17 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58 (Suppl. 06) S3-43 DOI: 10.1016/s0016-5107(03)02159-x. (PMID: 14652541)
• 18 Endoscopic Classification Review Group. Update on the Paris classification of superficial neoplastic lesions in the digestive tract. Endoscopy 2005; 37: 570-578 DOI: 10.1055/s-2005-861352. (PMID: 15933932)
• 19 Bret J, Mark B, Patrick R. et al. Colonoscopy training in gastroenterology fellowships: determining competence. Gastrointest Endosc 2010; 71: 319-324
• 20 Arimoto J, Chiba H, Ashikari K. et al. Safety and efficacy of cold snare polypectomy for pedunculated (Ip) polyps measuring less than 10 mm in diameter. Int J Colorectal Dis 2020; 35: 859-867
• 21 Arimoto J, Chiba H, Ashikari K. et al. Management of less than 10-mm-sized pedunculated polyps with thin stalk: hot snare polypectomy versus cold snare polypectomy. Dig Dis Sci 2021; 66: 2353-2361
• 22 Arimoto J, Chiba H, Tachikawa J. et al. Evaluation of cold snare polypectomy for small pedunculated (Ip) polyps with thin stalks: a prospective clinical feasibility study. Scand J Gastroenterol 2022; 57: 253-259
• 23 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 DOI: 10.1016/j.gie.2013.08.040. (PMID: 24125514)
• 24 Arimoto J, Higurashi T, Chiba H. et al. Continued use of a single antiplatelet agent does not increase the risk of delayed bleeding after colorectal endoscopic submucosal dissection. Dig Dis Sci 2018; 63: 218-227
• 25 Tajiri H, Kitano S. Complication associated with endoscopic mucosal resection: definition of bleeding that can be viewed as accidental. Dig Endosc 2004; 16: S134-136
• 26 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; 4: 686-692 DOI: 10.1016/j.gie.2015.02.012. (PMID: 25922251)
• 27 Arimoto J, Chiba H, Higurashi T. et al. Risk factors for incomplete polyp resection after cold snare polypectomy. Int J Colorectal Dis 2019; 34: 1563-1569 DOI: 10.1007/s00384-019-03347-6. (PMID: 31312890)
• 28 Arimoto J, Higurashi T, Chiba H. et al. Investigation of the local recurrence rate after colorectal endoscopic mucosal resection: is incomplete polyp resection really a clinically important problem? Analysis of the rationale for the “resect and discard” strategy. Can J Gastroenterol Hepatol 2019; 8: 7243515
• 29 Repici A, Hassan C, Vietta E. et al. Safety of cold polypectomy for <10 mm polyps at colonoscopy: a prospective multicenter study. Endoscopy 2012; 44: 27-31
• 30 Zhang J, Yu KF. What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA 1998; 280: 1690-1691 DOI: 10.1001/jama.280.19.1690. (PMID: 9832001)
• 31 Chiba H, Tachikawa J, Arimoto J. et al. Predictive factors of mild and severe fibrosis in colorectal endoscopic submucosal dissection. Dig Dis Sci 2020; 65: 232-242 DOI: 10.1007/s10620-019-05735-y. (PMID: 31312991)