Cold Snare Polypectomy: Techniques and Applications

Cold Snare Polypectomy in Pediatric Polyposis: A Multicenter Experience

Background: Cold snare polypectomy (CSP) is a well-established and recommended technique in adult gastroenterology for the safe, efficient and complete removal of nonpedunculated lesions up to 10 mm, with piecemeal excision possible for larger lesions. However, the application of CSP in pediatric patients remains underexplored. This study summarizes a multicenter experience of CSP in pediatric polyposis patients, focusing on safety, efficacy and clinical outcomes. Methods: This retrospective study was conducted at two pediatric tertiary centers, encompassing patients aged 1 to 21 years with polyposis who underwent colonoscopy with CSP and hot snare polypectomy (HSP) between January 2022 and January 2023. Patient demographics, procedure characteristics, polyp details and clinical outcomes were analyzed. Results: A total of 477 CSPs were performed in 63 colonoscopies. Satisfactory bowel preparation was noted in 79% of procedures, with a pooled mean procedure duration of 52 min and cecal intubation achieved in 98%. Polyps resected by CSP ranged from 3 to 70 mm in size and were predominantly left-sided. Tissue retrieval was complete in 94% of cases and partial in 5%. Mild intraprocedural bleeding occurred in 25% of CSP cases, requiring endoclip placement in 19%, with no post-procedural bleeding or significant complications observed. Comparatively, CSP demonstrated favorable bleeding rates relative to HSP. At two-week follow-up, four patients required emergency evaluation for unrelated complaints, but with no adverse events attributed to CSP. Conclusions: CSP is a safe and effective technique for the removal of sessile polyps in pediatric patients with polyposis. Mild intraprocedural bleeding, when observed, was effectively managed with standard hemostatic techniques. These findings support the potential of CSP as a preferred modality for sessile polyp removal in pediatric patients, though further research is warranted to define its role across broader pediatric populations and practice settings.

Cold snare polypectomy: A closer look at the efficacy and limitations for polyps 10-20 mm in size

Current guidelines recommend cold snare polypectomy for polyps less than 10 mm in size. Conversely, endoscopic mucosal resection is still the preferred technique for larger polyps. Concerns regarding cold snare polypectomy for larger polyps revolve around the difficulty in conducting en-bloc resection (resulting in piecemeal removal), and the potential for local residual polyp tissue and a high rate of recurrence. On the other hand, cold snare technique has the advantages of shortening procedure time, reducing delayed bleeding risks and lowering cost of treatment. Numerous ongoing and recent studies are focused on evaluating the risks and benefits of this technique for polyps larger than 10 mm, with the goal of providing clear guidelines in the near future. The aim of this editorial is to provide our readers with an overview regarding this subject and the latest developments surrounding it.

AGA Clinical Practice Update on Appropriate and Tailored Polypectomy: Expert Review

DESCRIPTION

In this Clinical Practice Update (CPU), we provide guidance on the appropriate use of different polypectomy techniques. We focus on polyps <2 cm in size that are most commonly encountered by the practicing endoscopist, including use of classification systems to characterize polyps and various polypectomy methods. We review characteristics of polyps that require complex polypectomy techniques and provide guidance on which types of polyps require more advanced management by a therapeutic endoscopist or surgeon. This CPU does not provide a detailed review of complex polypectomy techniques, such as endoscopic submucosal dissection, which should only be performed by endoscopists with advanced training.

METHODS

This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: A structured visual assessment using high-definition white light and/or electronic chromoendoscopy and with photodocumentation should be conducted for all polyps found during routine colonoscopy. Closely inspect colorectal polyps for features of submucosally invasive cancer. BEST PRACTICE ADVICE 2: Use cold snare polypectomy for polyps <10 mm in size. Cold forceps polypectomy can alternatively be used for 1- to 3-mm polyps where cold snare polypectomy is technically difficult. BEST PRACTICE ADVICE 3: Do not use hot forceps polypectomy. BEST PRACTICE ADVICE 4: Clinicians should be familiar with various techniques, such as cold and hot snare polypectomy and endoscopic mucosal resection, to ensure effective, safe, and optimal resection of intermediate-size polyps (10-19 mm). BEST PRACTICE ADVICE 5: Consider using lifting agents or underwater endoscopic mucosal resection for removal of sessile polyps 10-19 mm in size. BEST PRACTICE ADVICE 6: Serrated polyps should be resected using cold resection techniques. Submucosal injection may be helpful for polyps >10 mm if margins cannot be well delineated. BEST PRACTICE ADVICE 7: Use hot snare polypectomy to remove pedunculated lesions >10 mm in size. BEST PRACTICE ADVICE 8: Do not routinely use clips to close resection sites for polyps <20 mm. BEST PRACTICE ADVICE 9: Refer patients with polyps to endoscopic referral centers in the context of size ≥20 mm, challenging polypectomy location, or recurrent polyp at a prior polypectomy site. BEST PRACTICE ADVICE 10: Tattoo lesions that may need future localization at endoscopy or surgery. Tattoos should be placed in a location that will not interfere with subsequent attempts at endoscopic resection. BEST PRACTICE ADVICE 11: Refer patients with nonpedunculated polyps with clear evidence of submucosally invasive cancer for surgical evaluation. BEST PRACTICE ADVICE 12: Understand the endoscopy suite's electrosurgical generator settings appropriate for polypectomy or postpolypectomy thermal techniques.

Combined Endoscopic Robotic Surgery for Complex Colon Polyps

BACKGROUND

Combined endoscopic robotic surgery is a surgical technique that modifies traditional endoscopic laparoscopic surgery with robotic assistance to aid in the removal of complex colonic polyps. This technique has been described in the literature but lacks patient follow-up data.

OBJECTIVE

This study aimed to evaluate the safety and outcomes of combined endoscopic robotic surgery.

DESIGN

A retrospective review of a prospective database.

SETTING

East Jefferson General Hospital, Metairie, Louisiana.

PATIENTS

Ninety-three consecutive patients who underwent combined endoscopic robotic surgery from March 2018 to October 2021 were included in the study.

MAIN OUTCOME MEASURES

Operative time, intraoperative complication, 30-day postoperative complication, hospital length of stay, and follow-up pathology report results were the main outcome measures.

RESULTS

Combined endoscopic robotic surgery was completed in 88 of 93 participants (95%). Among the 88 participants who completed combined endoscopic robotic surgery, the average age was 66 years (SD = 10), BMI was 28.8 kg/m 2 (SD = 6), and history of previous abdominal surgeries was 1 (SD = 1). Median operative time was 72 minutes (range, 31-184 minutes) and polyp size was 40 mm (range, 5-180 mm). The most common polyp locations were the cecum, ascending colon, and transverse colon (31%, 28%, 25%). Pathology mainly demonstrated tubular adenoma (76%). Data on 40 patients who underwent follow-up colonoscopy were available. The average follow-up time was 7 months (range, 3-22 months). One patient (2.5%) had polyp recurrence at the resection site.

LIMITATIONS

Limitations for our study include a lack of randomization and follow-up rate to assess for recurrence. The low compliance rate may be due to procedure cancelations/difficulty scheduling because of changing coronavirus disease 2019 guidelines.

CONCLUSIONS

Compared to literature-reported statistics for its laparoscopic counterpart, combined endoscopic robotic surgery was associated with decreased operation times and resection site polyp recurrence. See Video Abstract at http://links.lww.com/DCR/C208 .

CIRUGA ROBTICA ENDOSCPICA COMBINADA PARA PLIPOS DE COLON COMPLEJOS

ANTECEDENTES:La cirugía robótica endoscópica combinada es una técnica quirúrgica que modifica la cirugía laparoscópica endoscópica tradicional con asistencia robótica para ayudar en la extracción de pólipos colónicos complejos. Esta técnica está previamente descrita en la literatura, pero carece de datos de seguimiento de los pacientes.OBJETIVO:Evaluar la seguridad y los resultados de la cirugía robótica endoscópica combinada.DISEÑO:Revisión retrospectiva de una base de datos prospectiva.AJUSTE:Hospital General East Jefferson, Metairie LouisianaPACIENTES:Noventa y tres pacientes consecutivos y sometidos a cirugía robótica endoscópica combinada por un solo cirujano colorrectal desde marzo de 2018 hasta octubre de 2021.PRINCIPALES MEDIDAS DE RESULTADO:Tiempo operatorio, complicación intraoperatoria, complicación posoperatoria a los 30 días, duración de la estancia hospitalaria y resultados del informe patológico de seguimiento.RESULTADOS:La cirugía robótica endoscópica combinada se completó en 88 de 93 (95%). Entre los 88 participantes que completaron la cirugía robótica endoscópica combinada, la edad promedio fue de 66 años (desviación estándar = 10), índice de masa corporal de 28,8 (desviación estándar = 6) y el historial de cirugías abdominales previas de 1 (desviación estándar = 1). La mediana del tiempo operatorio y el tamaño de los pólipos fueron 72 minutos (rango 31-184 minutos) y 40 milímetros (rango 5-180 milímetros), respectivamente. Las ubicaciones de pólipos más comunes fueron el ciego, colon ascendente y transverso (31%, 28%, 25%). La patología demostró principalmente adenoma tubular (76%). Los datos de 40 pacientes sometidos a una colonoscopia de seguimiento estaban disponibles. El tiempo medio de seguimiento fue de 7 meses (rango 3-22 meses). Un paciente (2,5%) presentó recurrencia polipoidea en el sitio de resección.LIMITACIONES:Las limitaciones de nuestro estudio incluyeron la falta de aleatorización y la tasa de seguimiento para evaluar la recurrencia. La baja tasa de seguimiento puede deberse a la renuencia del paciente en hacerse una colonoscopia o cancelaciones de procedimientos por la dificultad para programar debido a cambios de COVID-19.CONCLUSIÓN:En comparación con las estadísticas reportadas en la literatura para su contraparte laparoscópica, la cirugía robótica endoscópica combinada se asoció con reducción en tiempos de operación y recurrencia de pólipos en el sitio de resección. Consulte Video Resumen en http://links.lww.com/DCR/C208 . (Traducción - Dr. Fidel Ruiz Healy ).

Research trends on endoscopic mucosal resection: A bibliometric analysis from 1991 to 2021

BACKGROUND

In recent years, the rapid development of digestive endoscopy technology has brought revolutionary changes to endoscopic therapy. A growing number of articles have been published annually. We aimed to explore global scientific outputs and hotspots of endoscopic mucosal resection (EMR) published by different countries, organizations, and authors.

METHODS

We extracted relevant publications from the Web of Science Core Collection (WOSCC) on June 23, 2022. We examined the retrieved data by bibliometric analysis (e.g., cocited and cluster analysis, keyword co-occurrence) using the software CiteSpace and VOSviewer to analyze and predict the trends and hot spots in this field.

RESULTS

A total of 2,695 papers were finally identified. The results showed that the number of articles fluctuated with the year and reached its peak in 2021. NATIONAL CANCER CENTER JAPAN was the most influential institution. MICHAEL J BOURKE and YUTAKA SAITO are two of the most prolific scholars. ENDOSCOPY and GASTROINTESTINAL ENDOSCOPY were the most productive journals. "Early gastric cancer" and "Barrett's esophagus" were the focus of EMR research. "Adverse events", "cold snare polypectomy" and "outcomes" have become increasingly popular in recent years and could become hot spots in the future.

CONCLUSION

In this study, we summarized the characteristics of the publications; identified the most influential countries, institutions, and journals; and identified the leading topics in the EMR field.

From advanced diagnosis to advanced resection in early neoplastic colorectal lesions: Never-ending and trending topics in the 2020s

Colonoscopy represents the most widespread and effective tool for the prevention and treatment of early stage preneoplastic and neoplastic lesions in the panorama of cancer screening. In the world there are different approaches to the topic of colorectal cancer prevention and screening: different starting ages (45-50 years); different initial screening tools such as fecal occult blood with immunohistochemical or immune-enzymatic tests; recto-sigmoidoscopy; and colonoscopy. The key aspects of this scenario are composed of a proper bowel preparation that ensures a valid diagnostic examination, experienced endoscopist in detection of preneoplastic and early neoplastic lesions and open-minded to upcoming artificial intelligence-aided examination, knowledge in the field of resection of these lesions (from cold-snaring, through endoscopic mucosal resection and endoscopic submucosal dissection, up to advanced tools), and management of complications.

A Comparison of Incomplete Resection Rate of Large and Small Colorectal Polyps by Cold Snare Polypectomy

BACKGROUND & AIMS

There are limited data regarding the safety and efficacy of cold snare polypectomy (CSP) for large colorectal polyps. We evaluated factors affecting the clinical outcomes of CSP for polyps between 5 and 15 mm in size.

METHODS

This was a prospective single-center observational study involving 1000 patients undergoing colonoscopy. Polyps (5-15 mm) were removed using CSP, and biopsies were taken from the resection margin. The primary outcome was the incomplete resection rate (IRR), and was determined by the presence of residual neoplasia on biopsy. Correlations between IRR and polyp size, morphology, histology, and resection time were assessed by generalized estimating equation model.

RESULTS

A total of 440 neoplastic polyps were removed from 261 patients. The overall IRR was 2.27%, 1.98% for small (5-9 mm) vs 3.45% for large (10-15 mm) polyps (P = .411). In univariate analysis, the IRR was more likely to be related to sessile serrated lesions (odds ratio [OR], 6.93; 95% confidence interval [CI], 1.88-25.45; P = .004), piecemeal resection (OR, 11.83; 95% CI, 1.20-116.49; P = .034), and prolonged resection time >60 seconds (OR, 7.56; 95% CI, 1.75-32.69; P = .007). In multivariable regression analysis, sessile serrated lesions (OR, 6.45; 95% CI, 1.48-28.03; P = .013) and resection time (OR, 7.39; 95% CI, 1.48-36.96; P = .015, respectively) were independent risk factors for IRR. Immediate bleeding was more frequent with resection of large polyps (6.90% vs 1.42%; P = .003). No recurrence was seen on follow-up colonoscopy in 37 cases with large polyps.

CONCLUSIONS

CSP is safe and effective for removal of colorectal polyps up to 15 mm in size, with a low IRR. (ClinicalTrials.gov; Number: NCT03647176).

Quality Indicators for the Detection and Removal of Colorectal Polyps and Interventions to Improve Them

Modifiable risk factors for postcolonoscopy colorectal cancer include suboptimal lesion detection (missed neoplasms) and inadequate lesion removal (incomplete polypectomy) during colonoscopy. Competent detection and removal of colorectal polyps are thus fundamental to ensuring adequate colonoscopy quality. Several well-researched quality metrics for polyp detection have been implemented into clinical practice, chief among these the adenoma detection rate. Less data are available on quality indicators for polyp removal, which currently include complete resection rates and skills assessment tools. This review summarizes the available literature on quality indicators for the detection and removal of colorectal polyps, as well as interventions to improve them.

Is Submucosal Injection Helpful in Cold Snare Polypectomy for Small Colorectal Polyps?

BACKGROUND/AIMS

Cold snare polypectomy (CSP) is an effective method of polyp removal for small colorectal polyps. However, the effect of submucosal injection in cold snare endoscopic mucosal resection (CS-EMR) for small polyps is unclear. Therefore, this study aimed to evaluate the effect of submucosal injection in CS-EMR for small polyps.

METHODS

Between 2018 and 2019, 100 consecutive small colorectal polyps (5-10 mm) were identified in 58 patients. The first 50 consecutive polyps were removed by CS-EMR, and the remaining 50 were removed by CSP. Demographic data, clinical data, endoscopic findings, procedure times, complication rates, and pathology data were collected.

RESULTS

No difference in the complete resection rate was observed between the CS-EMR and CSP groups. A total of 9 polyps showed post-polypectomy bleeding (7 had immediate bleeding, 1 had delayed bleeding, and 1 had both immediate and delayed bleeding). No difference in the bleeding rate was observed between the two groups. In multivariate analysis, warfarin (odds ratio [OR], 42.334; 95% confidence interval [CI], 1.006-1,781.758) and direct-acting oral anticoagulants (OR, 35.244; 95% CI, 3.853-322.397) showed a significantly increased risk of bleeding.

CONCLUSION

The effect of submucosal injection in CSP was not significant for small colorectal polyps.

Polypectomy Techniques

Polyps in the upper and lower gastrointestinal tract can be premalignant or malignant lesions that can be treated endoscopically in early stages to prevent morbidity and more invasive procedures. This article critically reviews the techniques available and provides recommendations for endoscopic polypectomy.