Complete polyp resection with cold snare versus hot snare polypectomy for polyps of 4–9 mm: a randomized controlled trial

Abstract

Background Endoscopic screening with polypectomy reduces the incidence of colorectal cancer (CRC). Incomplete polyp removal may attenuate the effect of screening. This randomized trial compared cold snare polypectomy (CSP) with hot snare polypectomy (HSP) in terms of complete polyp resection.

Methods We included patients ≥ 40 years of age at eight hospitals in four countries who had at least one non-pedunculated polyp of 4–9 mm detected at colonoscopy. Patients were randomized 1:1 to CSP or HSP. Biopsies from the resection margins were obtained systematically after polypectomy in both groups. We hypothesized that CSP would be non-inferior to HSP, with a non-inferiority margin of 5 %. Logistic regression models were fitted to identify the factors explaining incomplete resection.

Results 425 patients, with 601 polyps, randomized to either CSP or HSP were included in the analysis. Of 318 polyps removed by CSP and 283 polyps removed by HSP, 34 (10.7 %) and 21 (7.4 %) were incompletely resected, respectively, with an adjusted risk difference of 3.2 % (95 %CI −1.4 % to 7.8 %). There was no difference between the groups in terms of post-polypectomy bleeding, perforation, or abdominal pain. Independent risk factors for incomplete removal were serrated histology (odds ratio [OR] 3.96; 95 %CI 1.63 to 9.66) and hyperplastic histology (OR 2.52; 95 %CI 1.30 to 4.86) in adjusted analyses.

Conclusion In this randomized trial, non-inferiority for CSP could not be demonstrated. Polyps with serrated histology are more prone to incomplete resection compared with adenomas. CSP can be used safely for small polyps in routine colonoscopy practice.

Publication History

Received: 06 July 2021

Accepted after revision: 10 January 2022

Accepted Manuscript online:
10 January 2022

Article published online:
18 February 2022

• References

• 1 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
• 2 Holme O, Loberg M, Kalager M. et al. Effect of flexible sigmoidoscopy screening on colorectal cancer incidence and mortality: a randomized clinical trial. JAMA 2014; 312: 606-615
• 3 Schoen RE, Pinsky PF, Weissfeld JL. et al. Colorectal-cancer incidence and mortality with screening flexible sigmoidoscopy. NEJM 2012; 366: 2345-2357
• 4 Segnan N, Armaroli P, Bonelli L. et al. Once-only sigmoidoscopy in colorectal cancer screening: follow-up findings of the Italian Randomized Controlled Trial--SCORE. J Natl Cancer Inst 2011; 103: 1310-1322
• 5 Farrar WD, Sawhney MS, Nelson DB. et al. Colorectal cancers found after a complete colonoscopy. Clin Gastroenterol Hepatol 2006; 4: 1259-1264
• 6 Robertson DJ, Lieberman DA, Winawer SJ. et al. Colorectal cancers soon after colonoscopy: a pooled multicohort analysis. Gut 2014; 63: 949-956
• 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 Pedersen IB, Bretthauer M, Kalager M. et al. Incomplete endoscopic resection of colorectal polyps: a prospective quality assurance study. Endoscopy 2021; 53: 383-391
• 9 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
• 10 Levin TR, Zhao W, Conell C. et al. Complications of colonoscopy in an integrated health care delivery system. Ann Int Med 2006; 145: 880-886
• 11 Tolliver KA, Rex DK. Colonoscopic polypectomy. Gastroenterol Clin North Am 2008; 37: 229-251, ix
• 12 Tappero G, Gaia E, De Giuli P. et al. Cold snare excision of small colorectal polyps. Gastrointest Endosc 1992; 38: 310-313
• 13 Deenadayalu VP, Rex DK. Colon polyp retrieval after cold snaring. Gastrointest Endosc 2005; 62: 253-256
• 14 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-e348
• 15 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
• 16 Aslan F, Camci M, Alper E. et al. Cold snare polypectomy versus hot snare polypectomy in endoscopic treatment of small polyps. Turk J Gastroenterol 2014; 25: 279-283
• 17 Kawamura T, Takeuchi Y, Asai S. et al. A comparison of the resection rate for cold and hot snare polypectomy for 4–9 mm colorectal polyps: a multicentre randomised controlled trial (CRESCENT study). Gut 2018; 67: 1950-1957
• 18 Papastergiou V, Paraskeva KD, Fragaki M. et al. Cold versus hot endoscopic mucosal resection for nonpedunculated colorectal polyps sized 6–10 mm: a randomized trial. Endoscopy 2018; 50: 403-411
• 19 Zhang Q, Gao P, Han B. et al. Polypectomy for complete endoscopic resection of small colorectal polyps. Gastrointest Endosc 2018; 87: 733-740
• 20 Liu S, Ho SB, Krinsky ML. Quality of polyp resection during colonoscopy: are we achieving polyp clearance?. Dig Dis Sci 2012; 57: 1786-1791
• 21 Shinozaki S, Kobayashi Y, Hayashi Y. et al. Efficacy and safety of cold versus hot snare polypectomy for resecting small colorectal polyps: Systematic review and meta-analysis. Dig Endosc 2018; 30: 592-599
• 22 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
• 23 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
• 24 de Benito Sanz M, Hernández L, García-Martínez MI. et al. Efficacy and safety of cold vs hot snare polypectomy for small (5–9 mm) colorectal polyps: a multicenter randomized controlled trial. Endoscopy 2022; 54: 35-44
• 25 Jegadeesan R, Aziz M, Desai M. et al. Hot snare vs. cold snare polypectomy for endoscopic removal of 4 – 10 mm colorectal polyps during colonoscopy: a systematic review and meta-analysis of randomized controlled studies. . Endoscopy Int Open 2019; 7: E708-E716
• 26 Djinbachian R, Iratni R, Durand M. et al. Rates of incomplete resection of 1- to 20-mm colorectal polyps: a systematic review and meta-analysis. Gastroenterology 2020; 159: 904-914.e912
• 27 Gomez V, Badillo RJ, Crook JE. et al. Diminutive colorectal polyp resection comparing hot and cold snare and cold biopsy forceps polypectomy. Results of a pilot randomized, single-center study (with videos). . Endoscopy Int Open 2015; 3: E76-E80
• 28 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
• 29 Suzuki S, Gotoda T, Kusano C. et al. Width and depth of resection for small colorectal polyps: hot versus cold snare polypectomy. Gastrointest Endosc 2018; 87: 1095-1103
• 30 Vleugels JLA, Hazewinkel Y, Fockens P. et al. Natural history of diminutive and small colorectal polyps: a systematic literature review. Gastrointest Endosc 2017; 85: 1169-1176.e1161
• 31 Tutticci NJ, Hewett DG. Cold EMR of large sessile serrated polyps at colonoscopy (with video). Gastrointest Endosc 2018; 87: 837-842
• 32 Kimoto Y, Sakai E, Inamoto R. et al. Safety and efficacy of cold snare polypectomy without submucosal injection for large sessile serrated lesions: a prospective study. Clin Gastroenterol Hepatol 2020;
• 33 Corley DA, Jensen CD, Marks AR. et al. Adenoma detection rate and risk of colorectal cancer and death. NEJM 2014; 370: 1298-1306
• 34 Burr NE, Derbyshire E, Taylor J. et al. Variation in post-colonoscopy colorectal cancer across colonoscopy providers in English National Health Service: population based cohort study. BMJ 2019; 367: l6090