One-device colonoscopy: feasibility, cost savings, and plastic waste reduction by procedure indication, when performed by a high detecting colonoscopist

Abstract

Background Cold forceps and snares are each effective for removing polyps of 1–3 mm, while snares are more effective for polyps of 4–10 mm in size. If, in the same patient, polyps of 1–3 mm are removed with forceps and those of 4–10 mm with snares, two devices are used. If cold snares are used to resect all lesions of 1–10 mm (one-device colonoscopy), there is a potential for lower costs and less plastic waste.

Methods A single high detecting colonoscopist prospectively measured the feasibility of cold snaring all colorectal lesions of ≤10 mm in size, along with the associated costs and plastic waste reduction.

Results 677 consecutive lower gastrointestinal endoscopies (not for inflammatory bowel disease) were assessed. Of 1430 lesions of 1–3 mm and 1685 lesions of 4–10 mm in size, 1428 (99.9%, 95%CI 99.5%–100%) and 1674 (99.3%, 95%CI 98.8%–99.7%), respectively, were successfully resected using cold snaring. Among 379 screening and surveillance patients, universal cold snaring of lesions ≤10 mm saved 35 and 47 cold forceps per 100 screening and surveillance patients, respectively.

Conclusion Cold snare resection of all lesions ≤10 mm (one-device colonoscopy) was feasible, and reduced costs and plastic waste.

Introduction

Colonoscopic polyp resection utilizes disposable devices that add a cost and produce plastic waste. Gastrointestinal services are among the leading departments in plastic waste production [1] [2].

Cold snaring can reduce device use and plastic waste. For example, some endoscopists prefer cold forceps for lesions of 1–3 mm, and cold forceps are effective in this size range [3]. However, cold forceps are inappropriate for polyps ≥4 mm, as snaring is more effective [4]. Cold snaring all polyps ≤10 mm eliminates cold forceps use for polypectomy and reduces costs and plastic waste when patients have at least one polyp of 1–3 mm and another of ≥4 mm in size. Cold snaring can also be effective for some lesions of 11–15 mm [5] [6] and even 16–19 mm in size [6].

In this prospective assessment of consecutive colonoscopies performed by a single high detecting colonoscopist, we evaluated the feasibility of universal cold snaring of polyps ≤10 mm in size, and secondarily the impact on cost and reduction in plastic waste.

Methods

We conducted a prospective quality project from November 7, 2022 until February 3, 2023. Permission to review the deidentified database was granted by the Institutional Review Board at Indiana University on February 28, 2023.

Patients

We excluded inflammatory bowel disease patients, as it was anticipated that biopsy forceps would be needed either to sample suspected dysplasia or to assess histologic activity. All other patients were eligible.

Patients were grouped into nine indication categories: (i) polyp or cancer surveillance; (ii) screening; (iii) positive fecal test (positive fecal immunochemical test [FIT] or positive Cologuard [Exact Sciences, Madison, Wisconsin, USA]); (iv) Lynch syndrome; (v) familial adenomatous (FAP) or MUTYH-associated polyposis; (vi) serrated polyposis syndrome (SPS); (vii) diagnostic colonoscopy for symptoms; (viii) therapeutic procedure for polyp resection; or (ix) first or second surveillance after resection of a large colorectal polyp (separated from other surveillance because the colonoscopist often samples the resection scar with cold forceps [7]).

Procedures

Colonoscopies were performed by D.K.R. using high definition Olympus Exera III colonoscopes (Olympus Corporation, Center Valley, Pennsylvania, USA). During procedures, an assistant recorded each polyp’s location, size, shape, and the endoscopist’s histologic prediction [8]. Polyps were placed into separate containers for each colonic section. If multiple polyps were placed in the same container, the number of adenomas and serrated lesions was estimated retrospectively according to the endoscopist’s histology predictions.

All FAP patients had undergone subtotal colectomy or total proctocolectomy, but were included if the purpose of the procedure was polyp identification and removal. Therefore, pouchoscopies (four in FAP patients) and flexible sigmoidoscopies (n = 6; 3 for large polyp surveillance, 2 therapeutic, and 1 FAP) were included.

Approach to colonoscopy

The goal was to prospectively determine whether all lesions ≤10 mm, including pedunculated lesions [9], could be removed using cold snaring. Cold snaring in this study refers to snare resection without submucosal injection. Piecemeal cold snaring was extended to some sessile serrated lesions (SSLs) >10 mm [10], as well as some flat adenomas >10 mm in size [5]. Complete resection was defined endoscopically as complete removal of the lesion and a surrounding border of normal mucosa.

Lesions ≤10 mm were generally removed with a dedicated cold snare: the Boston Scientific Cap Cold (Boston Scientific, Marlborough, Massachusetts, USA) or, in a few instances, the Exacto (Steris Corp, Mentor, Ohio, USA). All lesions proximal to the sigmoid were resected. In the rectosigmoid all lesions with surface features of conventional adenomas [8] were resected. All NICE type 1 lesions >5 mm were resected. NICE type 1 lesions ≤5 mm were resected if they had large open pits, were relatively sessile (vs. flat), or at the discretion of the endoscopist one or more was removed to demonstrate hyperplastic pathology.

Definitions

Conventional adenomas were dysplastic lesions that could be described as tubular, tubulovillous, or villous. Serrated lesions included traditional serrated adenomas, SSLs with or without cytological dysplasia, and hyperplastic polyps. The adenoma detection rate (ADR) was the fraction of patients with ≥1 conventional adenoma or adenocarcinoma. The SSL detection rate (SSLDR) was the fraction with ≥1 SSL removed and verified by pathology. The polyp detection rate (PDR) was the fraction of patients with ≥1 polyp detected and verified by pathology as belonging to one of the above categories.

For cost analysis, we used the cost to our center of the Boston Scientific Radial Jaw 4 large capacity forceps ($9.20 per forceps). To determine the plastic waste reduction, we separated and weighed the plastic portion of the forceps (PG503-S DeltaRange; Mettler Toledo, Columbus, Ohio, USA).

Sample size

The primary end point was the feasibility of resecting all lesions ≤10 mm completely by cold snaring. Assuming 99% success in removing lesions of 1–3 mm with a snare, 330 lesions of 1–3 mm were required to establish success with 95% confidence and a 2% margin of error. SAS 9.4 (SAS Institute Inc, Cary, North Carolina, USA) was used for sample size calculation.

We sought to include this many polyps of 1–3 mm in size within the screening and surveillance population, because these populations are most important in terms of generalizability. Based on previous data from our center, we estimated 350 screening and surveillance patients would be needed to provide 400 polyps of 1–3 mm in size; however, the feasibility of the approach was assessed for patients with all indications.

Statistical analysis

We provide Clopper–Pearson 95%CIs for the success of cold snare resection by polyp size. Other results are descriptive. All analyses were conducted using SPSS 28 (IBM, New York, New York, USA).

Results

There were 677 patients without inflammatory bowel disease who underwent colonoscopy between November 7, 2022 and February 3, 2023.

Of 1430 total polyps of 1–3 mm in size, 1428 (99.9%, 95%CI 99.5%–100%) were completely removed by cold snaring ([Fig. 1] a; [Table 1]). Two polyps of 1–3 mm were recurrent lesions that were avulsed off scars using hot forceps. Within 379 routine screening and surveillance patients, all 684 lesions of 1–3 mm in size (100%) were successfully removed by cold snaring.

Fig. 1 Endoscopic images showing cold snaring of colonic polyps of: a 2mm in size; b 8mm in size.

Table 1 Resection methods of histologically confirmed polyps* by size range.

Polyp size, mm	Number of polyps	Successful resection by cold snare, n (%) [95%CI]	Other resection method				Clips used, n (%)	Hot avulsion used, n (%)
			Hot snare, n (%)	Cold EMR, n (%)	Cold forceps, n (%)	Hot EMR, n (%)
EMR, endoscopic mucosal resection. * Includes only conventional adenomas, traditional serrated adenomas, sessile serrated lesions, hyperplastic polyps, and lesions with cancer; there were 14 adenocarcinomas detected, six of which were resected endoscopically. † One lesion was endoscopically resected by avulsion only; in the second, avulsion was an adjunct to snare resection. ‡ 10 lesions in this group underwent biopsy only and did not undergo subsequent endoscopic resection. For polyps of this size, avulsion was used only as an adjunct to snare-based methods.
1–3	1430	1428 (99.9%) [99.5%–100%]	0	0	0	0	3 (0.2%)	2 (0.1%)
4–10	1685	1674 (99.3%) [98.8%–99.7%]	8 (0.5%)	0	0	2 (0.1%)	9 (0.5%)	2† (0.1%)
Total (≤10)	3115	3102 (99.6%) [99.3%–99.8%]	8 (0.3%)	0	0	2 (0.1%)	12 (0.4%)	4 (0.1%)
11–19	202	146 (72.3%) [65.6%–78.3%]	17 (8.4%)	29 (14.4%)	0	10 (5%)	25 (12.4%)	0
≥20	109‡	6 (5.5%) [2.0%–11.6%]	15 (13.8%)	26 (23.9%)	0	52 (47.7%)	52 (47.7%)	29 (26.6%)
Total (>10)	311	152 (48.9%) [43.2%–54.6%]	32 (10.3%)	55 (17.7%)	0	62 (19.9%)	77 (24.8%)	29 (9.3%)

Of 1685 polyps of 4–10 mm in size, 1674 (99.3%, 95%CI 98.8%–99.7%) were completely removed by cold snaring ([Fig. 1] b; [Table 1]). The remaining 11 lesions of 4–10 mm in size were removed using electrocautery because they were residual polyps on scars or referred as partly resected polyps (n = 9), or were referred with special features (pedunculated lesion that was difficult to access [n = 1] and a lesion within a diverticulum [n = 1]).

[Table 2] shows detection levels by indication, along with patient demographics, mean Boston Bowel Preparation Scale (BBPS) score, and the numbers of polyps removed by size category and indication.

Table 2 Patient demographics, Boston Bowel Preparation Scale (BBPS) scores, detection rates, and total polyps resected by procedure indication for the 677 lower gastrointestinal endoscopies.

Indication	n (%)	Age, mean (SD) [range]	Female, n (%)	White, n (%)	Total BBPS, mean (SD) [range]	ADR (n)	SSLDR (n)	PDR (n)	Number of polyps in each size range, mm
									1–3	4–10	>10
ADR, adenoma detection rate; SSLDR, serrated sessile lesion detection rate; PDR, polyp detection rate; FAP, Familial adenomatous polyposis.
Screening	105 (15.5)	56.4 (9.5) [29–81]	56 (53.3)	96 (91.4)	8.8 (0.7) [6–9]	50.5% (53)	8.6% (9)	75.2% (79)	148	154	15
Surveillance	274 (40.5)	65.9 (9.8) [18–90]	150 (54.7)	264 (96.4)	8.6 (1.0) [3–9]	61.3% (168)	8.8% (24)	83.6% (229)	536	521	25
Diagnosis of symptoms	35 (5.2)	55.2 (17.9) [24–93]	18 (51.4)	33 (94.3)	8.7 (1.4) [3–9]	51.4% (18)	5.7% (2)	62.9% (22)	19	36	10
Positive fecal tests	9 (91.3)	65.9 (9.9) [48–77]	8 (88.9)	9 (100)	9.0 (0.0) [9–9]	77.8% (7)	11.1% (1)	88.9% (8)	13	25	13
Serrated polyposis syndrome	28 (4.1)	67.6 (8.3) [45–84]	20 (71.4)	27 (96.4)	8.6 (0.9) [5–9]	53.6% (15)	25.0% (7)	100% (28)	191	232	29
Lynch syndrome	19 (2.8)	50.6 (15.9) [21–81]	9 (47.4)	17 (89.5)	8.6 (1.2) [4–9]	47.4% (9)	5.3% (1)	63.2% (12)	24	8	1
FAP	12 (1.8)	37.8 (13.5) [18–57]	7 (58.3)	12 (100)	8.8 (0.9) [6–9]	75.0% (9)	0.0% (0)	75.0% (9)	186	131	3
Therapeutic for polyp resection	133 (19.6)	64.3 (9.6) [38–83]	69 (51.9	121 (91.0)	8.6 (1.1) [3–9]	86.5% (115)	9.0% (12)	97.0% (129)	196	364	199
First or second surveillance after polyp resection	62 (9.2)	63.4 (11.1) [36–84]	37 (59.7)	58 (93.5)	8.7 (0.8) [6–9]	72.6% (45)	3.2% (2)	90.3% (56)	117	214	16

[Table 3] shows by indication the numbers of patients with only polyps ≤3 mm, only polyps of 4–10 mm, and number with polyps of both ≤3 mm and 4–10 mm. Patients with polyps of both 1–3 mm and 4–10 mm are those where a biopsy forceps can be saved by cold snaring all lesions ≤10 mm. This fraction of patients ranged from 20% for patients undergoing colonoscopy for diagnosis of symptoms to 85.7% for SPS patients; it was 35.2% among the screening group and 47.4% for the surveillance patients. Among the 379 screening and surveillance patients, use of cold snaring only to resect all lesions of 1–10 mm in size (as opposed to forceps for lesions 1–3 mm and a snare for lesions 4–10 mm) would save 167 cold forceps, equivalent to 44 cold forceps per 100 screening and surveillance patients (35 per 100 screening patients and 47 per 100 surveillance patients). The reduction in device cost was $3.21 per screening colonoscopy and $4.32 per surveillance colonoscopy. Including the plastic in the device and packaging of the Radial Jaw 4 large capacity forceps, the plastic waste reduction was 11 g per screening procedure and 14.7 g per surveillance procedure.

Table 3 Fraction of patients with various different size polyps and managed entirely by cold snaring in the different size groups, by indication.

Indication	Percentage of patients (n) with each finding				Percentage of patients (n/N) managed entirely with cold snaring			Percentage of patients (n) with cold forceps biopsy for diagnostic purposes
	No polyp	Only polyps ≤3 mm	Only polyps of 4–10 mm	Polyps of ≤3 mm and 4–10 mm	Only polyps of 1–10 mm	Only polyps >10 mm	Polyps of 1–10 mm and >10 mm
FAP, familial adenomatous polyposis.
Screening (n = 105)	24.8% (26)	20.0% (21)	19.0% (20)	35.2% (37)	100% (67/67)	0.0% (0/1)	81.8% (9/11)	3.8% (4)
Surveillance (n = 274)	16.4% (45)	18.6% (51)	17.2% (47)	47.4% (130)	99.0% (206/208)	100% (1/1)	95.0% (19/20)	5.8% (16)
Diagnosis of symptoms (n = 35)	37.1% (13)	8.6% (3)	25.7% (9)	20.0% (7)	100% (14/14)	100% (3/3)	80.0% (4/5)	40.0% (14)
Positive fecal tests (n = 9)	11.1% (1)	0	55.6% (5)	33.3% (3)	100% (3/3)	0	60.0% (3/5)	11.1% (1)
Serrated polyposis syndrome (n = 28)	0	3.6% (1)	10.7% (3)	85.7% (24)	100% (16/16)	0	66.7% (8/12)	3.6% (1)
Lynch syndrome (n = 19)	36.8% (7)	31.6% (6)	10.5% (2)	21.1% (4)	100% (11/11)	0	100% (1/1)	10.5% (2)
FAP (n = 12)	25.0% (3)	8.3% (1)	0	66.7% (8)	100% (6/6)	0	33.3% (1/3)	0
Therapeutic for polyp resection (n = 133)	3.0% (4)	6.0% (8)	21.1% (28)	36.8% (49)	68.8% (11/16)	6.8% (3/44)	13.0% (9/69)	12.8% (17)
First or second surveillance after large polyp resection (n = 62)	9.7% (6)	12.9% (8)	12.9% (8)	62.9% (39)	97.8% (44/45)	100% (1/1)	90.0% (9/10)	80.6% (50)

[Table 3] also lists the numbers of cases where biopsy forceps were used for other purposes, such as microscopic colitis in diarrhea, biopsying cancers, or biopsying endoscopic mucosal resection (EMR) scars in patients undergoing surveillance after EMR. These patients offset the cold forceps savings from only using snares for lesions of 1–10 mm. The number of patients requiring biopsy forceps for diagnostic purposes was highest for patients undergoing EMR surveillance and diagnosis of symptoms, but was low for other indications ([Table 3]). Finally, we used cold snare piecemeal resection without EMR to remove a substantial fraction of lesions ≥10 mm ([Table 1]).

[Table 3] also shows the fractions of patients with polyps in the different size ranges that required only the cold snare to perform their colonoscopies. For patients undergoing screening and surveillance colonoscopy, this fraction exceeded 95% for patients with only polyps ≤10 mm and substantial fractions of patients who also had lesions >10 mm. All of the patients with polyposis syndromes (FAP and SPS) who had only lesions of 1–10 mm in size were managed with cold snaring alone.

Discussion

We prospectively assessed the feasibility of cold snaring all colorectal lesions ≤10 mm, including lesions of 1–3 mm in size. We found this approach to be completely feasible, except in rare cases where a tiny lesion was located on a scar and required avulsion. We found that using a cold snare to resect all polyps ≤10 mm would save 35 and 47 cold forceps per 100 screening and 100 surveillance patients, respectively. The number of forceps saved would vary between physicians depending on their detection skill and the indications for colonoscopy encountered in individual practices. Therefore, the study is a proof of principle and demonstration project, but it suggests useful savings and waste reduction would be encountered across most practices. The absolute level of savings in cold forceps demonstrated here is less important than the demonstration that cold snare resection of essentially all lesions ≤10 mm is feasible and that, for a high-level detector, the prevalence of patients with one or more lesions of 1–3 mm and one or more lesions of 4–10 mm is substantial.

The strengths of this study include its prospective nature and that considerable evidence supports the safety and efficacy of cold snaring for lesions ≤10 mm in size [11] [12] [13]. Therefore, our study is only an assessment of the impact of principles already established.

The study limitations include the procedures being performed by an expert endoscopist. Some endoscopists may have difficulty achieving universal cold snare resection of polyps ≤10 mm in size, but we have demonstrated the potential benefit achievable by striving for universal cold snare resection of polyps ≤10 mm. We note cold snaring is inappropriate when endoscopic inspection leads to cancer suspicion, because cold snaring cuts superficially compared with hot snaring [14] [15] [16]. We previously demonstrated extremely low invasive cancer risk in lesions ≤10 mm [17], and there were no invasive cancers found in this study (data not shown). The appropriateness of cold snare resection for each lesion depends however on its endoscopic features. We note submucosal injection is unnecessary before cold snaring lesions ≤10 mm [11] [12] [13], and produces additional cost and waste.

Finally, cold snaring risks tissue loss for pathology assessment compared with forceps resection. We did not submit each polyp separately to pathology (see Methods), but we retrieved tissue from the only polyp in a colon segment or another polyp in the same segment for 99.7% of lesions of 1–10 mm in size (data not shown), suggesting high retrieval rates. Regardless, pathology is an imperfect gold standard for lesions of 1–3 mm, owing to tissue fragmentation and limited sectioning of tissue blocks [18] [19]. This justifies our use of endoscopist prediction to determine the final counts of tiny adenomas. We suggest tissue loss with cold snaring is of limited importance for most endoscopists.

We perform large numbers of cold forceps biopsies of EMR scars to increase the identification of any residual polyp [7]. Recent studies have found routine biopsy can be replaced by detailed inspection of EMR scars using enhanced imaging [20]. Therefore, abandoning this practice would further reduce forceps use in our practice ([Table 3]).

In conclusion, universal cold snaring of lesions ≤10 mm is feasible and reduces costs and plastic waste, compared with cold forceps resection for polyps of 1–3 mm and cold snare resection for larger lesions. We recommend colonoscopists strive for cold snaring of all lesions ≤10 mm, except when inspection raises a concern of cancer.

Conflict of Interest

D.K. Rex has provided consultancy to Olympus Corporation, Boston Scientific, Braintree Laboratories, Norgine, Medtronic, and Acacia Pharmaceuticals; and has received research support from Olympus Corporation, Medivators, Erbe USA Inc., and Braintree Laboratories; he is a shareholder in Satisfai Health. K. Vemulapalli is employed by Cook Medical. P. Sharma is a consultant for Olympus Corporation, Boston Scientific, Salix Pharmaceuticals, Cipla, Medtronic, Takeda, Samsung Bioepis, and CDx; and has received grant support from ERBE and Fujifilm. C. Hassan has provided consultancy to Fujifilm Co., Olympus Corp., Medtronic Co., and has received research support from NEC and Odin. J.A. Gallagher and R.E. Lahr declare that they have no conflict of interest.

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Publication History

Received: 13 July 2023

Accepted after revision: 10 October 2023

Accepted Manuscript online:
10 October 2023

Article published online:
28 November 2023