Is cold biopsy forceps resection of diminutive polyps really so inadequate?

I read with great interest the elegant albeit small study by Efthymiou et al. [1], suggesting that cold biopsy forceps resection of diminutive polyps was complete in only 39 %. It remains difficult to understand why neither polyp size (< 3 mm vs. > 3 mm) nor the number of bites (< 2 vs. > 2) influenced the completeness of resection. One would expect that polyps of < 3 mm would be resected easily by forceps of 7 mm if the endoscopist targets the resection correctly.

Cold forceps resection is undoubtedly the quickest way to resect small polyps with the lowest complication rate and the highest polyp retrieval rate. It is also the cheapest method as no snare is involved. I use two additional principles, which definitely make me feel more confident in favor of cold forceps resection: first, I always resect slightly beyond the tissue that has been visualized, which means that even for a very small polyp, at least 2 – 3 bites are necessary; secondly, my main test after resection is abundant ongoing rinsing, which produces “underwater” endoscopic images, permitting a very detailed, magnified inspection of the resection site. Any residual tissue can be easily identified and resected. It is not clear whether the authors allude to this technique in the method section by stating that “no visible tissue was seen following washing with water.” If yes, their disappointing results are difficult to understand and indeed warrant further investigation by comparing cold forceps resection using the two above-mentioned technical precautions with cold snare resection.

References

• 1 Efthymiou M, Taylor A C, Desmond P V. et al . Biopsy forceps is inadequate for the resection of diminutive polyps.  Endoscopy. 2011;  43 312-316