Cold snare endoscopic mucosal resection versus standard hot technique for large flat nonpedunculated colonic lesions: a randomized controlled trial

Abstract

Backgrounds Cold snare EMR (CS-EMR) in large flat nonpedunculated colonic lesions (LFNPCLs) is an alternative to the standard EMR procedure with a better safety profile, but scientific evidence on its efficacy is unavailable. This study aimed to compare the recurrence rate between the two techniques at 6 months. Secondary aims were comparison of the safety profile and procedure-related outcomes.

Methods This was a noninferiority, multicenter, open-label, randomized controlled trial of consecutive large (≥ 20 mm) LFNPCLs without suspicious features of submucosal invasion.

Results 229 patients were randomized to receive CS-EMR (n = 115) or EMR (n = 114). The median lesion size was 25 mm and 74.6 % were adenomas. The trial was stopped early by clinical consensus according to a safety monitoring board. At first surveillance colonoscopy (n = 220) the recurrence rate was significantly greater in the CS-EMR group than in the EMR group: 33.0 % vs. 16.2 % (P = 0.004) and 34.7 % vs. 14.8 % (P = 0.001) in the intention-to-treat and per-protocol analyses, respectively. According to the subgroup analysis, the recurrence rate was significantly greater after CS-EMR for LFNPCLs ≥ 30 mm (43.1 % vs. 18.2 %). There was no difference in the rate of adverse events. The use of clips was more common in the EMR group (52.6 % vs. 27.8 %).

Conclusions The recurrence rate of LFNPCLs after CS-EMR was significantly greater than after the standard hot technique. A similar safety profile was found between groups.

• References

• 1 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
• 2 Moss A, Williams SJ, Hourigan LF. et al. Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut 2015; 64: 57-65
• 3 Thoguluva Chandrasekar V, Spadaccini M, Aziz M. et al. Cold snare endoscopic resection of nonpedunculated colorectal polyps larger than 10 mm: a systematic review and pooled-analysis. Gastrointest Endosc 2019; 89: 929-936.e3
• 4 Tutticci NJ, Kheir AO, Hewett DG. The cold revolution: how far can it go?. Gastrointest Endosc Clin N Am 2019; 29: 721-736
• 5 Ito A, Suga T, Ota H. et al. Resection depth and layer of cold snare polypectomy versus endoscopic mucosal resection. J Gastroenterol 2018; 53: 1171-1178
• 6 Tate DJ, Awadie H, Bahin FF. et al. Wide-field piecemeal cold snare polypectomy of large sessile serrated polyps without a submucosal injection is safe. Endoscopy 2018; 50: 248-252
• 7 Mangira D, Cameron K, Simons K. et al. Cold snare piecemeal EMR of large sessile colonic polyps ≥20 mm (with video). Gastrointest Endosc 2020; 91: 1343-1352
• 8 van Hattem WA, Shahidi N, Vosko S. et al. Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods. Gut 2021; 70: 1691-1697
• 9 O’Sullivan T, Cronin O, van Hattem WA. et al. Cold versus hot snare endoscopic mucosal resection for large (≥15 mm) flat non-pedunculated colorectal polyps: a randomised controlled trial. Gut 2024; 73: 1823-1830
• 10 Schulz KF, Altman DG, Moher D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010; 340: c332
• 11 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon – November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: S3-43
• 12 Veitch AM, Vanbiervliet G, Gershlick AH. et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Endoscopy 2016; 48: 385-402
• 13 Rodríguez Sánchez J, Sánchez Alonso M, Pellisé Urquiza M. The bubble sign: a novel way to detect a perforation after cold snare polypectomy. Endoscopy 2019; 51: 796-797
• 14 Watanabe T, Itabashi M, Shimada Y. et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) Guidelines 2014 for treatment of colorectal cancer. Int J Clin Oncol 2015; 20: 207-239
• 15 Hashiguchi Y, Muro K, Saito Y. et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer. Int J Clin Oncol 2020; 25: 1-42
• 16 Dean AG, Sullivan KM, Soe MM. OpenEpi: open source epidemiologic statistics for public health, version 3.01. Updated April 6, 2013. www.OpenEpi.com
• 17 Suresh S, Zhang J, Ahmed A. et al. Risk factors associated with adenoma recurrence following cold snare endoscopic mucosal resection of polyps ≥20 mm: a retrospective chart review. Endosc Int Open 2021; 9: E867-E873
• 18 Steinbrück I, Ebigbo A, Kuellmer A. et al. Cold versus hot snare endoscopic resection of large non-pedunculated colorectal polyps (randomized-controlled German CHRONICLE-trial). Gastroenterology 2024; 167: 764-777
• 19 Núñez-Pizarro JL, Luzko I, Rivero-Sánchez L. Postpolypectomy syndrome after multiple cold‐snare polypectomies in the rectum. Dig Endosc 2023; 35: 928-928
• 20 Tate DJ, Desomer L, Argenziano ME. et al. Treatment of adenoma recurrence after endoscopic mucosal resection. Gut 2023; 72: 1875-1886
• 21 Ferlitsch M, Hassan C, Bisschops R. et al. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2024. Endoscopy 2024; 56: 516-545
• 22 Mehta D, Loutfy AH, Kushnir VM. et al. Cold versus hot endoscopic mucosal resection for large sessile colon polyps: a cost-effectiveness analysis. Endoscopy 2022; 54: 367-375