Cold versus hot endoscopic mucosal resection for nonpedunculated colorectal polyps sized 6–10 mm: a randomized trial

Abstract

Background and study aims Cold snare polypectomy is an established method for the resection of small colorectal polyps; however, significant incomplete resection rates still leave room for improvement. We aimed to assess the efficacy of cold snare endoscopic mucosal resection (CS-EMR), compared with hot snare endoscopic mucosal resection (HS-EMR), for nonpedunculated polyps sized 6 – 10 mm.

Patients and methods This study was a dual-center, randomized, noninferiority trial. Consecutive adult patients with at least one nonpedunculated polyp sized 6 – 10 mm were enrolled. Eligible polyps were randomized (1:1) to be treated with either CS-EMR or HS-EMR. Both methods involved submucosal injection of a methylene blue-tinted normal saline solution. The primary noninferiority end point was histological eradication evaluated by postpolypectomy biopsies (noninferiority margin – 10 %). Secondary outcomes included occurrence of intraprocedural bleeding, clinically significant postprocedural bleeding, and perforation.

Results Among 689 patients screened, 155 patients with 164 eligible polyps were included (CS-EMR n = 83, HS-EMR n = 81). The overall rate of histological complete resection was 92.8 % in the CS-EMR group and 96.3 % in the HS-EMR group (difference 3.5 %; 95 % confidence interval [CI] – 4.15 to 11.56), showing noninferiority of CS-EMR compared with HS-EMR. CS-EMR was shown to be noninferior both for polyps measuring 6 – 7 mm (CS-EMR 93.3 %; HS-EMR 100 %; 95 %CI – 7.95 to 21.3) and those of 8 – 10 mm (92.5 % vs. 94.7 %, respectively; 95 %CI – 7.91 to 13.16). Rates of intraprocedural bleeding were similar between the two groups (CS-EMR 3.6 %, HS-EMR 1.2 %; P  = 0.30). No clinically significant postprocedural bleeding or perforation occurred in either group.

Conclusions CS-EMR appears to be a valuable modification of the standard cold snare technique, obviating the need to use diathermy for nonpedunculated colorectal polyps sized 6 – 10 mm.

• References

• 1 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
• 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
• 3 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
• 4 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
• 5 Farrar WD, Sawhney MS, Nelson DB. et al. Colorectal cancers found after a complete colonoscopy. Clin Gastroenterol Hepatol 2006; 4: 1259-1264
• 6 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
• 7 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 e71
• 8 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
• 9 Paspatis GA, Tribonias G, Konstantinidis K. et al. A prospective randomized comparison of cold vs hot snare polypectomy in the occurrence of postpolypectomy bleeding in small colonic polyps. Colorectal Dis 2011; 13: e345-348
• 10 Repici A, Hassan C, Vitetta E. et al. Safety of cold polypectomy for <10mm polyps at colonoscopy: a prospective multicenter study. Endoscopy 2012; 44: 27-31
• 11 Aslan F, Camci M, Alper E. et al. Cold snare polypectomy versus hot snare polypectomy in endoscopic treatment of small polyps. Turkish J Gastroenterol 2014; 25: 279-283
• 12 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297
• 13 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
• 14 Anderloni A, Jovani M, Hassan C. et al. Advances, problems, and complications of polypectomy. Clin Exp Gastroenterol 2014; 7: 285-296
• 15 ASGE Technology Committee, Hwang JH, Konda V et al. Endoscopic mucosal resection. Gastrointest Endosc 2015; 82: 215-226
• 16 Horiuchi A, Makino T, Kajiyama M. et al. Comparison between endoscopic mucosal resection and hot snare resection of large nonpedunculated colorectal polyps: a randomized trial. Endoscopy 2016; 48: 646-651
• 17 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
• 18 [Anonymous]. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: S3-43
• 19 Bosman F, Carneiro F, Hruban R. et al. WHO classification of tumors of the digestive system. 4th edn. France: IARC; 2010
• 20 Hewett DG. Cold snare polypectomy: optimizing technique and technology (with videos). Gastrointest Endosc 2015; 82: 693-696
• 21 Paraskeva KD, Tribonias G, Papastergiou V. et al. In search of the optimal technique to overcome cold polypectomy cutting failure: pulling up may be better than resnaring (with video). Gastrointest Endosc 2016; 83: 854-855
• 22 Kim JS, Lee BI, 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
• 23 Din S, Ball AJ, Riley SA. et al. A randomized comparison of cold snare polypectomy versus a suction pseudopolyp technique. Endoscopy 2015; 47: 1005-1010
• 24 Park SK, Ko BM, Han JP. et al. A prospective randomized comparative study of cold forceps polypectomy by using narrow-band imaging endoscopy versus cold snare polypectomy in patients with diminutive colorectal polyps. Gastrointest Endosc 2016; 83: 527-532 e521
• 25 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
• 26 Matsuura N, Takeuchi Y, Yamashina T. et al. Incomplete resection rate of cold snare polypectomy: a prospective single-arm observational study. Endoscopy 2017; 49: 251-257
• 27 von Renteln D, Pohl H. Pushing the limit: how to get the most out of cold snares. Am J Gastroenterol 2016; 111: 1217-1219
• 28 Efthymiou M, Taylor AC, Desmond PV. et al. Biopsy forceps is inadequate for the resection of diminutive polyps. Endoscopy 2011; 43: 312-316
• 29 Lee SH, Chung IK, Kim SJ. et al. Comparison of postpolypectomy bleeding between epinephrine and saline submucosal injection for large colon polyps by conventional polypectomy: a prospective randomized, multicenter study. World J Gastroenterol 2007; 13: 2973-2977
• 30 Makino T, Horiuchi A, Kajiyama M. et al. Delayed bleeding following cold snare polypectomy for small colorectal polyps in patients taking antithrombotic agents. J Clin Gastroenterol 2017;
• 31 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