Incomplete resection rate of cold snare polypectomy: a prospective single-arm observational study

Abstract

Background and study aims Cold snare polypectomy (CSP) is considered to be safe for the removal of subcentimeter colorectal polyps. This study aimed to determine the rate of incomplete CSP resection for subcentimeter neoplastic polyps at our center.

Patients and methods Patients with small or diminutive adenomas (diameter 1 – 9 mm) were recruited to undergo CSP until no polyp was visible. After CSP, a 1 – 3 mm margin around the resection site was removed using endoscopic mucosal resection. The polyps and resection site marginal specimens were microscopically evaluated. Incomplete resection was defined as the presence of neoplastic tissue in the marginal specimen. We also calculated the frequency at which the polyp lateral margins could be assessed for completeness of resection.

Results A total of 307 subcentimeter neoplastic polyps were removed from 120 patients. The incomplete resection rate was 3.9 % (95 % confidence interval [CI] 1.7 % – 6.1 %); incomplete resection was not associated with polyp size, location, morphology, or operator experience. The polyp lateral margins could not be assessed adequately for 206 polyps (67.1 %). Interobserver agreement between incomplete resection and lateral polyp margins that were inadequate for assessment was poor (κ = 0.029, 95 %CI 0 – 0.04). Female sex was an independent risk factor for incomplete resection (odds ratio 4.41, 95 %CI 1.26 – 15.48; P  = 0.02).

Conclusions At our center, CSP resection was associated with a moderate rate of incomplete resection, which was not associated with polyp characteristics. However, adequate evaluation of resection may not be routinely possible using the lateral margin from subcentimeter polyps that were removed using CSP.

Trial registered at University Hospital Medical Information Network (UMIN 000010879).

• References

• 1 Siegel R, Naishadham D, Jemal A. CA Cancer. J Clin 2012; 62: 10-29
• 2 Morison B. President’s address: the polyp-cancer sequence in the large bowel. Proc R Soc Med 1974; 67: 451-457
• 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
• 4 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
• 5 Pohl H, Srivastava A, Bensen SP. et al. Incomplete polyp resection during colonoscopy-results of the complete adenoma resection (CARE) study. Gastroenterology 2013; 144: 74-80
• 6 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
• 7 British Society of Gastroenterology. Colonoscopic polypectomy and endoscopic mucosal resection: a practical guide. Available at: http://www.bsg.org.uk/clinical-guidance/endoscopy/colonoscopic-polypectomy-and-endoscopic-mucosal-resection-a-practical-guide.html Accessed 8 December 2014
• 8 Tajiri H, Kitano S. Complications associated with endoscopic mucosal resection: definition of bleeding that can be viewed accidental. Dig Endosc 2004; 16: 134-136
• 9 Yamashina T, Takeuchi Y, Uedo N. et al. Features of electrocoagulation syndrome after endoscopic submucosal dissection for colorectal neoplasm. J Gastroenterol Hepatol 2016; 31: 615-620
• 10 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
• 11 Tappero G, Gaia E, De Giuli P. et al. Cold snare excision of small colorectal polyps. Gastrointest Endosc 1992; 38: 310-313
• 12 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
• 13 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
• 14 Farrar WD, Sawhney MS, Nelson DB. et al. Colorectal cancers found after a complete colonoscopy. Clin Gastroenterol Hepatol 2006; 4: 1259-1264
• 15 Pabby A, Schoen RE, Weissfeld JL. et al. Analysis of colorectal cancer occurrence during surveillance colonoscopy in the dietary Polyp Prevention Trial. Gastrointest Endosc 2005; 61: 385-391
• 16 Takeuchi Y, Inoue T, Hanaoka N. et al. Autofluorescence imaging with a transparent hood for detection of colorectal neoplasms: a prospective, randomized trial. Gastrointest Endosc 2010; 72: 1006-1013
• 17 Takeuchi Y, Inoue T, Hanaoka N. et al. Surveillance colonoscopy using a transparent hood and image-enhanced endoscopy. Dig Endosc 2010; 22: 47-53
• 18 Participants in the Paris Workshop. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon – November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: 3-43
• 19 Hewett DG, Kaltenbach T, Sano Y. et al. Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging. Gastroenterology 2012; 143: 599-607
• 20 Dixon MF. Gastrointestinal epithelial neoplasia: Vienna revisited. Gut 2002; 51: 130-131
• 21 Sugisaka H, Ikegami M, Kijima H. et al. Pathological features of remnant or recurrent colonic lesions after endoscopic mucosal resection. Endoscopia Digestive 2003; 15: 951-956
• 22 Schoenfeld D. Statistical considerations for pilot studies. Int J Radiat Oncol Biol Phys 1980; 6: 371-374
• 23 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
• 24 Kim JS, Lee 1 B, 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
• 25 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
• 26 Takeuchi Y, Hanafusa M, Kanzaki H. et al. An alternative option for “resect and discard” strategy, using magnifying narrow-band imaging: a prospective “proof-of-principle” study. J Gastroenterol 2015; 50: 1017-1026
• 27 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