Safety and efficacy of cold snare polypectomy for small colorectal polyps: A prospective randomized control trial and one-year follow-up study

Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024

1:  ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of diminutive polyps (≤ 5 mm).Strong recommendation, high quality of evidence. 2:  ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3:  ESGE recommends CSP, to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of small polyps (6-9 mm).Strong recommendation, high quality of evidence. 4:  ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10-19 mm in size.Strong recommendation, high quality of evidence. 5:  ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥ 20 mm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6:  ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7:  Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥ 20 mm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8:  ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9:  ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10:  ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11:  ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.

Systematic review and meta-analysis of cold snare polypectomy and hot snare polypectomy for colorectal polyps

BACKGROUND AND AIM

Cold snare polypectomy (CSP) has become increasingly utilized to resect colorectal polyps, given its efficacy and safety. This study aims to compare CSP and hot snare polypectomy (HSP) for resecting small (< 10 mm) and large (10-20 mm) colorectal lesions.

METHODS

Relevant publications were obtained from Cochrane Library, Embase, Google Scholar, PubMed, and Web of Science databases. The publication search was limited by English-language and human studies. Pooled mean difference and odds ratios (ORs) were calculated for outcomes of interest.

RESULTS

Twenty-three studies were included in this meta-analysis. Pooled OR of delayed post-polypectomy bleeding (DPPB) in the CSP group versus the HSP group was 0.29 (P = 0.0001, I2  = 29%). Subgroup analysis according to lesion size showed a significant reduction in the DPPB rate in lesion sizes 10-20 mm (pooled OR 0.08, P = 0.003, I2  = 0%) and < 10 mm (pooled OR 0.35, P = 0.001, I2  = 27%). Pooled OR of major bleeding in the CSP group was 0.23 (P = 0.0004, I2  = 0%). Subgroup analysis by lesion size revealed a significant decrease in the rate of major bleeding in the CSP group for both lesion sizes 10-20 mm (pooled OR 0.11, P = 0.04) and < 10 mm (pooled OR 0.26, P = 0.003). Complete resection, en bloc resection, and recurrence rate were comparable in the two groups.

CONCLUSIONS

Cold snare polypectomy was associated with a lower rate of DPPB and lower risk of major bleeding compared with HSP in both small and large polyps. CSP should be considered as the polypectomy technique of choice for colorectal polyps.

Cold Versus Hot Snare Polypectomy for Colorectal Polyps: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVE

Endoscopic polypectomy is an excellent tool for colon cancer prevention. With the innovation of novel resection techniques, the best method is still being investigated. Hence, we aim to evaluate the efficacy and safety of cold snare polypectomy (CSP) versus hot snare polypectomy (HSP) for colorectal polyp resection.

METHODS

A systematic review and meta-analysis synthesizing evidence from randomized controlled trials retrieved from PubMed, EMBASE, WOS, SCOPUS, and CENTRAL until July 16, 2022. We pooled dichotomous outcomes using risk ratio (RR) with the corresponding CI. This review's protocol was prospectively registered in PROSPERO with ID: CRD42022347496.

RESULTS

We included 18 randomized controlled trials with a total of 4317 patients and 7509 polyps. Pooled RR favored HSP regarding the complete resection rate (RR: 0.96 with 95% CI: 0.95, 1, P = 0.03) and local recurrence incidence (RR: 5.74 with 95% CI: 1.27, 25.8, P = 0.02). Pooled RR favored CSP regarding the colonoscopy time (mean difference: -6.50 with 95% CI: -7.55, -5.44, P = 0.00001) and polypectomy time (mean difference: -57.36 with 95% CI: -81.74, -32.98, P = 0.00001). There was no difference regarding the incidence of immediate bleeding ( P = 0.06) and perforation ( P = 0.39); however, HSP was associated with more incidence of delayed bleeding ( P = 0.01), abdominal pain ( P = 0.007), and postresection syndrome ( P = 0.02).

DISCUSSION

HSP is associated with a higher complete resection and lower recurrence rates; however, HSP is also associated with a higher incidence of adverse events. Therefore, improving the complete resection rate with CSP still warrants more innovation, giving the technique safety and shorter procedure duration.

The efficacy and safety of cold snare versus hot snare polypectomy for endoscopic removal of small colorectal polyps: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

The optimal technique for removing small colorectal polyps ranging from 5 to 10 mm in size remains uncertain. In order to compare the efficacy and adverse events between cold snare polypectomy (CSP) and hot snare polypectomy (HSP) for removing small polyps, we conducted a systematic review and meta-analysis of available randomized controlled trials.

METHODS

We conducted a comprehensive search of MEDLINE, EMBASE, and the Cochrane Library databases from 1998 to May 2023 to identify randomized controlled trials that evaluated the efficacy and safety of cold snare polypectomy (CSP) and hot snare polypectomy (HSP) for resecting small colorectal polyps. The primary outcome measure was the incomplete resection rate (IRR).

RESULTS

Seven studies that met our study criteria, with a total of 3178 included polyps, were included in our analysis. The incomplete resection rate (IRR) was found to be significantly higher in the CSP group compared to the HSP group (risk ratio [RR] 1.57 [1.17-2.11], P = 0.003). Although the CSP group had a higher local recurrence rate than the HSP group, the difference was not statistically significant (RR: 3.98 [0.66-23.84], P = 0.13). The polyp retrieval rates were not significantly different between the two groups (RR: 1.00 [0.99-1], P = 0.22). Perforation was not reported or mentioned in any of the seven studies. The overall immediate bleeding rate was significantly higher in the CSP group than the HSP group (RR: 2.26 [1.63-3.14], P < 0.001), but immediate postpolypectomy bleeding requiring additional intervention was similar between the groups (RR: 1.08 [0.54-2.17], P = 0.82). The delayed bleeding rate (RR: 0.83 [0.45-1.55], P = 0.56) and specific polypectomy time (RR: -0.46 [-1.05-0.12], P = 0.12) were also similar between the groups.

CONCLUSIONS

The meta-analysis shows a significantly higher IRR for CSP compared with HSP when removing small polyps.

A Comparative Analysis of the Efficacy and Safety of Hot Snare Polypectomy and Cold Snare Polypectomy for Removing Small Colorectal Polyps: A Systematic Review and Meta-Analysis

Both cold snare polypectomy (CSP) and hot snare polypectomy (HSP) have been shown to be effective methods for removing small colorectal polyps, but the optimal method for achieving complete resection remains unclear. To address this issue, we conducted a systematic search of relevant articles using databases such as PubMed, ProQuest, and EBSCOhost. The search criteria included randomized controlled trials that compared CSP and HSP for small colorectal polyps ≤10 mm and the articles were screened based on specific inclusion and exclusion criteria. The data were analyzed using RevMan software (version 5.4; Cochrane Collaboration, London, United Kingdom), and meta-analysis was performed with outcomes measured using pooled odds ratios (OR) and 95% confidence intervals (CI). The Mantel-Haenszel random effect model was used to calculate the OR. We selected a total of 14 randomized controlled trials involving 11601 polyps for analysis. Pooled analysis showed no statistically significant difference in the incomplete resection rate between CSP and HSP (OR: 1.22; 95% CI: 0.88-1.73, p-value: 0.27; I2: 51%), en bloc resection rate (OR: 0.66; 95%CI: 0.38-1.13; p: 0.13; I2: 60%), and polyp retrieval rate (OR: 0.97; 95%CI: 0.59-1.57; p: 0.89; I2: 17%). For safety endpoints, there is no statistically significant difference in intraprocedural bleeding rate between CSP and HSP per patient analysis (OR: 2.37, 95% CI: 0.74-7.54; p: 0.95; I2: 74%) and per polyp basis (OR: 1.84, 95% CI: 0.72-4.72; p: 0.20; I2: 85%). CSP had lower OR for the delayed bleeding outcome when compared with the HSP group per patient basis (OR: 0.42; 95% CI: 0.2-0.86; p: 0.02; I2: 25%), but not in the per polyp analysis (OR: 0.59; 95% CI: 0.12-3; p: 0.53; I2: 0%). Total polypectomy time was significantly shorter in the CSP group (mean difference: -0.81 minutes; 95% CI: -0.96, -0.66; p:<0.00001; I2: 0%). Thus, CSP is both an efficacious and safe method for removing small colorectal polyps. Therefore, it can be recommended as a suitable alternative to HSP for the removal of small colorectal polyps. However, more studies are necessary to evaluate any long-term differences between the two methods such as polyp recurrence rates.

Different endoscopic treatments for small colorectal polyps: A systematic review, pair-wise, and network meta-analysis

Background and study aims

In recent years, cold snare polypectomy (CSP) has been increasingly used for small polyps (<10 mm) instead of hot snare polypectomy (HSP). However, evidence-based research regarding the effectiveness and safety of CSP and HSP are still lacking. Additionally, for 4-10 -mm non-pedunculated polyps, the polyp removal method is still controversial. Therefore, it is clinically significant to conduct pair-wise and network meta-analyses to assess such resection methods.

Methods

We searched PubMed, Embase, and the Cochrane library for randomized controlled trials (RCTs). Only studies that involved the resection of polyps <10 mm were included. Outcomes included the complete resection rate, polyp retrieval rate, procedure-related complications, and procedure times.

Results

Overall, 23 RCTs (5,352 patients) were identified. In meta-analysis compared CSP versus HSP for polyps <10 mm, CSP showed lower complete resection rate than HSP although with no statistically significant difference [odds ratio (OR): 0.77, 95% confidence interval (CI): 0.56-1.06]. CSP showed a lower risk of major post-polypectomy complications compared to HSP (OR: 0.28, 95% CI: 0.11-0.73). In the network meta-analysis for 4-10 mm non-pedunculated polyps, HSP, and endoscopic mucosal resection (EMR) showed a higher complete resection rate than CSP (OR: 2.7, 95% CI: 1.3-9.2 vs. OR: 2.6, 95% CI: 1.0-10) but a significantly longer time than CSP (WMD: 16.55 s, 95% CI [7.48 s, 25.25 s], p < 0.001), (WMD: 48.00 s, 95% CI [16.54 s, 79.46 s], p = 0.003). Underwater CSP ranked third for complete resection with no complications.

Conclusion

For <10 mm polyps, CSP is safer than HSP, especially for patients taking antithrombotic drugs. For 4-10 mm non-pedunculated polyps, HSP, and EMR have higher complete resection rates than CSP.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022315575.

Comparative efficacy and safety of resection techniques for treating 6 to 20mm, nonpedunculated colorectal polyps: A systematic review and network meta-analysis

INTRODUCTION

Various endoscopic resection techniques have been proposed for the treatment of nonpedunculated colorectal polyps sized 6-20 mm, however the optimal technique still remains unclear.

METHODS

A comprehensive literature review was conducted for randomized controlled trials (RCTs), investigating the efficacy of endoscopic treatments for the management of 6-20 mm nonpedunculated colorectal polyps. Primary outcomes were complete and en bloc resection rates and adverse event rate was the secondary. Effect size on outcomes is presented as risk ratio (RR; 95% confidence interval [CI]).

RESULTS

Fourteen RCTs (5219 polypectomies) were included. Endoscopic mucosal resection(EMR) significantly outperformed cold snare polypectomy(CSP) in terms of complete [(RR 95%CI): 1.04(1.00-1.07)] and en bloc resection rate [RR:1.12(1.04-1.21)]. EMR was superior to hot snare polypectomy (HSP) [RR:1.04(1.00-1.08)] regarding complete resection, while underwater EMR (U-EMR) achieved significantly higher rate of en bloc resection compared to CSP [RR:1.15(1.01-1.30)]. EMR yielded the highest ranking for complete resection(SUCRA-score 0.81), followed by cold-snare EMR(CS-EMR,SUCRA-score 0.76). None of the modalities was different regarding adverse event rate compared to CSP, however EMR and CS-EMR resulted in fewer adverse events compared to HSP [RR:0.44(0.26-0.77) and 0.43(0.21-0.87),respectively].

CONCLUSION

EMR achieved the highest performance in resecting 6-20 mm nonpedunculated colorectal polyps, with this effect being consistent for polyps 6-9 and ≥10 mm; findings supported by very low quality of evidence.

Snare devices with thinner loop wire may provide higher performance for cold snare polypectomy in an experimental model

Background and study aims  Snare devices play an important role in treatment of intestinal polyps. However, there are no objective measurements for the characteristics of the various types of snare devices. Materials and methods  Seven types of snare devices from four manufacturers were evaluated based on original measurements. The evaluated factors were stiffness, cutting quality, and change in force required for cutting depending on sheath shape. The latter two factors were evaluated by measuring the force required to cut 20 % gelatin cylinders, which simulated intestinal polyps. The cutting sharpness was evaluated by observing the sectional surface of cut gelatin cylinders using a stereomicroscope. The correlations between these measurements and characteristics of the snare devices were investigated. Results  A strong positive correlation, with an R 2 value of 0.863, was shown between the force required to cut gelatin cylinders and loop wire diameter. Loop wire diameter also had a strong correlation, with an R 2 value of 0.7997, with the change in force required for cutting gelatin cylinders depending on sheath shape. No correlations were detected between loop stiffness and characteristics of snare devices. The edge-enhanced image revealed that the rougher surfaces of the gelatin cylinders were cut by snares with a thicker diameter. Conclusions  Thinner loop wire may provide higher performance in cold snare polypectomy in an experimental model.