Safety of cold polypectomy for < 10 mm polyps at colonoscopy: a prospective multicenter study

Background: Cold polypectomy techniques (without electrocautery) by means of biopsy forceps or snare are widely adopted for the removal of subcentimetric polyps. However, few data are available on the safety of this approach. The aim of this study was to assess the safety of cold polypectomy for subcentimetric polyps, as well as the rate of advanced neoplasia in these lesions.

Patients and methods: In a prospective multicenter trial, consecutive patients with at least one < 10-mm polyp at colonoscopy were prospectively included. All of the < 10-mm polyps detected within the study period were removed by cold polypectomy. The rates of immediate or delayed bleeding and other complications were assessed at 7 and 30 days after cold polypectomy by telephone calls. The rate of advanced histology was also assessed. Predictive variables of postpolypectomy bleeding or advanced neoplasia were identified by multivariate analysis.

Results: A total of 1015 < 10-mm polyps in 823 patients (15.5 % on antiplatelet agents) were removed. Of these, 822 (81 %) were ≤ 5 mm and 193 (19 %) were 6 – 9 mm. Immediate postpolypectomy bleeding occurred in 18 patients, corresponding to a per-patient and per-polyp bleeding rate of 2.2 % (95 % confidence interval [CI] 1.2 % – 3.2 %) and 1.8 % (95 %CI 1 % – 2.6 %), respectively. Therapy with antiplatelet agents (odds ratio [OR] 4; 95 %CI 1.5 – 10.6) and larger polyp size (OR 2; 95 %CI 1.1 – 6.9) were independent predictors of bleeding. Bleeding was successfully treated by endoscopic hemostasis in all cases and required no further medical intervention. Advanced neoplasia prevalence in polyps ≤ 5 mm was as high as 8.7 %.

Conclusions: The results from this study showed the high safety of a cold polypectomy approach for subcentimetric polyps. This was due to the low rate of postpolypectomy bleeding and to the high efficacy of endoscopic hemostasis in its treatment. The high rate of advanced neoplasia in polyps ≤ 5 mm should prompt some caution on the management of these lesions following detection at computed tomography colonography or colon capsule endoscopy.

• References

• 1 Boyle P, Ferlay J. Cancer incidence and mortality in Europe, 2004. Ann Oncol 2005; 16: 481-488
• 2 Weir HK, Thun MJ, Hankey BF et al. Annual report to the nation on the status of cancer, 1975–2000, featuring the uses of surveillance data for cancer prevention and control. J Natl Cancer Inst 2003; 95: 1276-1299
• 3 Atkin WS, Edwards R, Kralj-Hans I et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010; 375: 1624-1633
• 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 Citarda F, Tomaselli G, Capocaccia R et al. Efficacy in standard clinical practice of colonoscopic polypectomy in reducing colorectal cancer incidence. Gut 2001; 48: 812-815
• 6 Heldwein W, Dollhopf M, Rösch T et al. The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies. Endoscopy 2005; 37: 1116-1122
• 7 Panteris V, Haringsma J, Kuipers EJ. Colonoscopy perforation rate, mechanisms and outcome: from diagnostic to therapeutic colonoscopy. Endoscopy 2009; 41: 941-951
• 8 Regula J, Rupinski M, Kraszewska E et al. Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia. N Engl J Med 2006; 355: 1863-1872
• 9 Lieberman D, Moravec M, Holub J et al. Polyp size and advanced histology in patients undergoing colonoscopy screening: implications for CT colonography. Gastroenterology 2008; 135: 1100-1105
• 10 Tappero G, Gaia E, De Giuli P et al. Cold snare excision of small colorectal polyps. Gastrointest Endosc 1992; 38: 310-313
• 11 Fatima H, Rex DK. Minimizing endoscopic complications: colonoscopic polypectomy. Gastrointest Endosc Clin N Am 2007; 17: 145-156
• 12 Deenadayalu VP, Rex DK. Colon polyp retrieval after cold snaring. Gastrointest Endosc 2005; 62: 253-256
• 13 Pickhardt PJ, Choi JR, Hwang I et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med 2003; 349: 2191-2200
• 14 Eliakim R, Yassin K, Niv Y et al. Prospective multicenter performance evaluation of the second-generation colon capsule compared with colonoscopy. Endoscopy 2009; 41: 1026-1031
• 15 Lieberman D. Debate: small (6–9 mm) and diminutive (1–5 mm) polyps noted on CTC: how should they be managed?. Gastrointest Endosc Clin N Am 2010; 20: 239-243
• 16 Hassan C, Pickhardt PJ, Kim DH et al. Systematic review: distribution of advanced neoplasia according to polyp size at screening colonoscopy. Aliment Pharmacol Ther 2010; 31: 210-217
• 17 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
• 18 Singh N, Harrison M, Rex DK. A survey of colonoscopic polypectomy practices among clinical gastroenterologists. Gastrointest Endosc 2004; 60: 414-418
• 19 Weston AP, Campbell DR. Diminutive colonic polyps: histopathology, spatial distribution, concomitant significant lesions, and treatment complications. Am J Gastroenterol 1995; 90: 24-28
• 20 Graser A, Stieber P, Nagel D et al. Comparison of CT colonography, colonoscopy, sigmoidoscopy and faecal occult blood tests for the detection of advanced adenoma in an average risk population. Gut 2009; 58: 241-248
• 21 Rex DK, Alikhan M, Cummings O et al. Accuracy of pathologic interpretation of colorectal polyps by general pathologists in community practice. Gastrointest Endosc 1999; 50: 468-474
• 22 Efthymiou M, Taylor AC, Desmond PV et al. Biopsy forceps is inadequate for the resection of diminutive polyps. Endoscopy 2011; 43: 312-316
• 23 Hewett DG, Rex DK. Colonoscopy and diminutive polyps: hot or cold biopsy or snare? Do I send to pathology? . Clin Gastroenterol Hepatol 2011; 9: 102-105
• 24 Deenadayalu VP, Rex DK. Colon polyp retrieval after cold snaring. Gastrointest Endosc 2005; 62: 253-256
• 25 ASGE Standards of Practice Committee Anderson MA, Ben-Menachem T. et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70: 1060-1070