Complications of cold versus hot snare polypectomy of 10-20 mm polyps: A retrospective cohort study

Cold Endoscopic Mucosal Resection (c-EMR) of Nonpedunculated Colorectal Polyps ≥20 mm: A Systematic Review and Meta-analysis

BACKGROUND

There is increasing evidence that cold endoscopic mucosal resection (c-EMR) can effectively treat large colorectal polyps. We aim to appraise the current literature and evaluate outcomes following c-EMR for nonpedunculated colonic polyps ≥20 mm.

METHODS

Major databases were searched. Primary outcomes included recurrence rate and adverse events. Meta-analysis was performed using a random-effects model.

RESULTS

Nine articles were included in the final analysis, which included 817 patients and 1077 colorectal polyps. Average polyp size was 28.8 (±5.1) mm. The pooled recurrence rate of polyps of any histology at 4 to 6 months was 21.0% (95% CI: 9.0%-32.0%, P <0.001, I2 =97.3, P <0.001). Subgroup analysis showed that recurrence was 10% for proximal lesions (95% CI: 0.0%-20.0%, P =0.054, I2 =93.7%, P =0.054) and 9% for distal lesions (95% CI: 2.0%-21.0%, P =0.114, I2 =95.8%, P =0.114). Furthermore, subgroup analysis showed that recurrence was 12% for adenoma (95% CI: 4.0%-19.0%, P =0.003, I2 =98.0%, P =0.003), and 3% for sessile serrated polyps (95% CI: 1.0%-5.0%, P =0.002, I2 =34.4%, P =0.002). Post-polypectomy bleeding occurred in 1% (n=8/817) of patients, whereas abdominal pain occurred in 0.2% (n=2/817) of patients.

CONCLUSIONS

C-EMR for nonpedunculated colorectal polyps ≥20 mm shows an excellent safety profile with a very low rate of delayed bleeding as well as significantly less recurrence for sessile serrated polyps than adenomas.

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.

The Safety of Cold Versus Hot Snare Polypectomy in Polyps 10-20 mm: A Systematic Review and Meta-Analysis

Colonoscopy remains the primary method for preventing colorectal cancer. Traditionally, hot snare polypectomy (HSP) was the method of choice for removing polyps larger than 5 mm. Yet, for polyps smaller than 10 mm, cold snare polypectomy (CSP) has become the favored approach. Lately, the use of CSP has expanded to include the removal of sessile polyps that are between 10 and 20 mm in size. Our systematic review and meta-analysis aimed to evaluate the safety of cold snare polypectomy (CSP) compared to hot snare polypectomy (HSP) for resecting polyps measuring 10-20 mm. We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, and Cochrane databases up to April 2020 to find studies that directly compared CSP to HSP for polyps larger than 10 mm. Our main focus was on assessing the risk of delayed bleeding after polypectomy; a secondary focus was the incidence of any adverse events that required medical intervention post procedure. Our search yielded three comparative studies, two observational studies, and one randomized controlled trial (RCT), together encompassing 1,193 polypectomy procedures. Of these, 485 were performed using CSP and 708 with HSP. The pooled odds ratio (OR) for post-polypectomy bleeding (PPB) was 0.36 (95% confidence interval {CI}: 0.02, 7.13), with a Cochran Q test P-value of 0.11 and an I2 of 53%. For the risk of any adverse events necessitating medical care, the pooled OR was 0.15 (95% CI: 0.01, 2.29), with a Cochran Q test P-value of 0.21 and an I2 of 35%. The quality of the two observational studies was deemed moderate, and the RCT was only available in abstract form, preventing quality assessment. Our analysis suggests that there is no significant difference in the incidence of delayed post-polypectomy bleeding or other adverse events requiring medical attention between CSP and HSP for polyps measuring 10-20 mm.

Updates on the Prevention and Management of Post-Polypectomy Bleeding in the Colon

Post-polypectomy bleeding (PPB) remains a significant procedure-related complication, with multiple risk factors determining the risk including patient demographics, polyp characteristics, endoscopist expertise, and techniques of polypectomy. Immediate PPB is usually treated promptly, but management of delayed PPB can be challenging. Cold snare polypectomy is the optimal technique for small sessile polyps with hot snare polypectomy for pedunculated and large sessile polyps. Topical hemostatic powders and gels are being investigated for the prevention and management of PPB. Further studies are needed to compare these topical agents with conventional therapy.

Endoscopic band ligation versus hot snare resection for hyperplastic gastric polyps in cirrhotic patients

Managing patients with liver cirrhosis and gastric hyperplastic polyps (GHPs) is challenging. Despite being the standard technique for resection of GHPs, hot snare polypectomy (HSP) is risky in the setting of coagulation disorders associated with liver cirrhosis. The aim of the study was to assess the efficacy and safety of endoscopic band ligation (EBL), compared to HSP in resecting GHPs in cirrhotic patients. One hundred consecutive adults with liver cirrhosis and sessile or pedunculated GHPs were enrolled from December 2018 to December 2020. Cases were non-blindly randomized (1 : 1) to two groups to have GHPs managed by either EBL (group I) or HSP (group II). Data of demographic, clinical, and pathological factors, hospitalization expenses and outcomes of both treatment maneuvers were collected and statistically analyzed. Upper endoscopy was repeated for all patients at 3, 6 and 12 months after treatment for recurrence detection. Between the two procedures, the mean operational time was significantly shorter in the EBL than the HSP group (15.1 ±3.80 min vs. 36.6 ±6.72 min, p < 0.001). Concerning complications, 94% of EBL cases had reported no complications compared to 78% with HSP. Bleeding occurred only with HSP (20%) with urgent need for adrenaline and/or argon plasma coagulation (p = 0.003). Regarding cost, it was significantly lower in EBL than HSP (280 ±2.02 EGP vs. 390 ±181.8 EGP, p < 0.001). However, the recurrence rate of GHPs and number of needed sessions were not significantly different. EBL proved to be a safer, more rapid, and economic maneuver when compared to HSP on resecting GHPs in patients with liver cirrhosis.

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.

Hot snare polypectomy vs endoscopic mucosal resection using bipolar snare for intermediate size colorectal lesions: Propensity score matching

BACKGROUND

Endoscopic resection (ER) with bipolar snare, in which the electric current only passes through the tissue between the device’s two electrodes, is a prominent method used to prevent perforation due to electricity potentially. ER using bipolar snare with or without submucosal injection enabled safe resection of colorectal lesions measuring 10–15 mm in an ex vivo porcine model. ER with bipolar snare is expected to have good treatment outcomes in 10–15 mm colorectal lesions, with high safety even without submucosal injection. However, no clinical reports have compared treatment outcomes with and without submucosal injection.

AIM

To compare the treatment outcomes of bipolar polypectomy with hot snare polypectomy (HSP) to those with endoscopic mucosal resection (EMR).

METHODS

In this single-centre retrospective study, we enrolled 10–15 mm nonpedunculated colorectal lesions (565 Lesions in 463 patients) diagnosed as type 2A based on the Japan Narrow-band Imaging Expert Team classification, resected by either HSP or EMR between January 2018 and June 2021 at the National Cancer Center Hospital East. Lesions were divided into HSP and EMR groups, and propensity score matching was performed. In the matched cohort, en bloc and R0 resection rates and adverse events were compared between the two groups.

RESULTS

Of the 565 lesions in 463 patients, 117 lesions each in the HSP and EMR groups were selected after propensity score matching. In the original cohort, there was a significant difference in antithrombotic drug use (P < 0.05), lesion size (P < 0.01), location (P < 0.01), and macroscopic type (P < 0.05) between the HSP and EMR groups. In the matched cohort, the en bloc resection rates were comparable between both groups [93.2% (109/117) vs 92.3% (108/117), P = 0.81], and there was no significant difference in the R0 resection rate [77.8% (91/117) vs 80.3% (94/117), P = 0.64]. The incidence of delayed bleeding was similar in both groups [1.7% (2/117)]. Perforation occurred in the EMR group [0.9% (1/117)] but not in the HSP group.

CONCLUSION

Using bipolar snare, ER of nonpedunculated 10–15 mm colorectal lesions may be performed safely and effectively, even without submucosal injection.

Efficacy and Safety of Cold Snare Polypectomy of Colorectal Polyps 10-15 mm with a Hybrid Snare: A Prospective Observational Pilot Study

INTRODUCTION

Cold snare polypectomy (CSP) is a safe and effective procedure for small colorectal polyps ≤9 mm. There are only limited data regarding CSP of larger neoplastic lesions. This study evaluated the efficacy and safety of CSP for polyps between 10 and 15 mm in size.

METHODS

In this prospective single-arm observational pilot study, patients with a least one polyp 10-15 mm were included. These polyps were preferably removed by CSP using a dedicated hybrid snare. The primary outcome was the histological complete resection rate (CRR) determined by pathologically negative margins of the specimen and no neoplastic tissue obtained from biopsies of the resection site margin. Secondary outcomes were en bloc resection rate, failure of CSP, and incidence of adverse events.

RESULTS

A total of 61 neoplastic polyps were removed from 39 patients. Overall CRR was 80.3% (49/61). CSP was feasible in 78.7% (48/61) of polyps and the CRR in this group was 85.4% (41/48). When CSP failed (13/61; 21.3%), lesions were successfully resected by immediate HSP using the same snare with a CRR of 61.5% (8/13) in this group. One patient presented delayed hemorrhage after HSP of a polyp but successful hemostasis was achieved with two hemoclips. No other adverse events occurred. No recurrence was seen on follow-up colonoscopy in cases with incomplete resected polyps.

CONCLUSION

CSP seems to be efficient and safe in removing colorectal polyps up to 15 mm. A hybrid snare seems to be particularly advantageous for these polyps as it allows immediate conversion to HSP if CSP might fail in larger polyps. This trial is registered at ClinicalTrials.gov (NCT04464837).

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.

Incomplete resection rates of 4- to 20-mm non-pedunculated colorectal polyps when using wide-field cold snare resection with routine submucosal injection

Background and study aims  Incomplete resection of 4- to 20-mm colorectal polyps occur frequently (> 10 %), putting patients at risk for post-colonoscopy colorectal cancer. We hypothesized that routine use of wide-field cold snare resection with submucosal injection (CSP-SI) might reduce incomplete resection rates (IRRs). Patients and methods  Patients aged 45 to 80 years undergoing elective colonoscopies were enrolled in a prospective clinical study. All 4- to 20-mm non-pedunculated polyps were resected using CSP-SI. Post-polypectomy margin biopsies were obtained to determine IRRs through histopathology assessment. The primary outcome was IRR, defined as remnant polyp tissue found on margin biopsies. Secondary outcomes included technical success and complication rates. Results  A total of 429 patients (median age 65 years, 47.1 % female, adenoma detection rate 40 %) with 204 non-pedunculated colorectal polyps 4 to 20 mm removed using CSP-SI were included in the final analysis. CSP-SI was technical successful in 97.5 % (199/204) of cases (5 conversion to hot snare polypectomy). IRR for CSP-SI was 3.8 % (7/183) (95 % confidence interval [CI] 2.7 %-5.5 %). IRR was 1.6 % (2/129), 16 % (4/25), and 3.4 % (1/29) for adenomas, serrated lesions, and hyperplastic polyps respectively. IRR was 2.3 % (2/87), 6.3 % (4/64), 4.0 % (6/151), and 3.1 % (1/32) for polyps 4 to 5 mm, 6 to 9 mm, < 10 mm, and 10 to 20 mm, respectively. There were no CSP-SI-related serious adverse events. Conclusions  Use of CSP-SI results in lower IRRs compared to what has previously been reported in the literature for hot or cold snare polypectomy when not using wide-field cold snare resection with submucosal injection. CSP-SI showed an excellent safety and efficacy profile, however comparative studies to CSP without SI are required to confirm these results.

Comparison of cold snare and hot snare polypectomy for the resection of sporadic nonampullary duodenal adenomas

BACKGROUND AND AIMS

Nonampullary duodenal adenomas can undergo malignant transformation, making endoscopic resection, often by hot snare (HSP) or cold snare polypectomy (CSP), necessary. Although CSP has been shown to be safer for removal of colon polyps, data comparing these techniques for the resection of duodenal adenomas are limited. Our aim was to compare the safety and efficacy of CSP and HSP for the removal of nonampullary duodenal adenomas.

METHODS

We performed a retrospective cohort study of patients referred to 2 academic medical centers with a histologically confirmed sporadic, nonampullary duodenal adenoma who underwent endoscopic snare polypectomy between January 1, 2007 and March 1, 2021. Patients with underlying polyposis syndromes were excluded. Outcomes included postprocedural adverse events and polyp recurrence.

RESULTS

Of 110 total patients, 69 underwent HSP and 41 underwent CSP. Intraprocedural bleeding was similar between both groups, but 7 patients in the HSP group experienced delayed adverse events versus none in the CSP group (P = .04). Fifty-four patients had complete polyp resection and subsequent surveillance endoscopies. Multivariate analysis showed polyp size to be associated with recurrence (per mm; odds ratio, 1.11; 95% confidence interval, 1.04-1.20; P < .01). Endoscopic resection technique (HSP vs CSP) was not a predictor of recurrence (P = .18).

CONCLUSIONS

HSP led to more delayed adverse events compared with CSP, whereas no significant differences on outcomes were noted, suggesting that CSP is equally effective and potentially safer for the removal of duodenal adenomas.

Cold snare polypectomy of colorectal polyps ≤ 10 mm on clopidogrel: Australian and New Zealand randomized controlled trial

Background and study aims Optimal peri-colonoscopic management of clopidogrel remains unclear. Cold snare polypectomy is safe and effective for removing polyps ≤ 10 mm and clips can control intraprocedural bleeding. We conducted a randomized controlled trial to compare continuation of clopidogrel versus temporary replacement of clopidogrel with aspirin for routine colonoscopy using cold snare polypectomy for polyps ≤ 10 mm.

Patients and methods Between August 2016 and August 2019, consenting participants at 12 centers were randomized to continuation of clopidogrel as a single or dual antiplatelet agent, or to temporarily take aspirin alone from 7 days prior to 2 days after routine colonoscopy. Endoscopists were blinded to group allocation. Cold snare polypectomy was used to remove polyps ≤ 10 mm, with endoscopic clips applied if intraprocedural bleeding continued for > 2 minutes. Follow-up was performed on Day 30. The trial was stopped early due to delayed patient enrollment.

Results Two hundred seventy-six consecutive polyps ≤ 10 mm were removed from 107 patients. Of the patients, 61.7 % were male with a median age of 69 years (interquartile range [IQR] 63 to 76.75). Fifty-nine patients continued on clopidogrel and 48 temporarily took aspirin instead. One hundred thirty-four polyps were removed from 49 patients who continued on clopidogrel vs 142 from 43 patients temporarily took aspirin instead (P = 0.33). Intraprocedural bleeding requiring clips occurred in 11 of 49 patients who continued on clopidogrel and in two of 43 patients who temporarily took replacing with aspirin instead (P = 0.02). More post-procedural minor bleeding was seen in the aspirin arm (six of 43 vs one of 49; P = 0.03). One patient in each arm had acute coronary syndrome, which was medically managed. None of the patients had clinically significant post-procedural bleeding.

Conclusions Continuation of clopidogrel in patients undergoing cold snare polypectomy for colorectal polyps ≤ 10 mm does not appear to increase the rate of clinically significant postpolypectomy bleeding. It is associated with an increase in intraprocedural bleeding, which can be successfully treated with clips.

Cold versus hot endoscopic mucosal resection for large sessile colon polyps: a cost-effectiveness analysis

BACKGROUND : For large sessile colorectal polyps (LSCPs), endoscopic mucosal resection without diathermy ("cold endoscopic mucosal resection [EMR]") is gaining popularity because of its safety advantages over conventional EMR ("hot EMR"). Polyp recurrence rates have been reported to be higher with cold EMR. Considering these differences, we performed a cost-effectiveness analysis of these two techniques. METHODS : A decision analysis model was constructed for EMR of an LSCP. The decision tree incorporated the EMR method, clip use, procedural mortality, adverse events and their management, and polyp recurrence. Outcomes included days of lost productivity and marginal cost difference. Adverse event and recurrence rates were extracted from the existing literature, giving emphasis to recent systematic reviews and randomized controlled trials. RESULTS : Through 30 months of follow-up, the average cost of removing an LSCP by cold EMR was US$5213, as compared to $6168 by hot EMR, yielding a $955 cost difference (95 % confidence interval $903-$1006). Average days of lost productivity were 6.2 days for cold EMR and 6.3 days for hot EMR. This cost advantage remained over several analyses accounting for variations in recurrence rates and clip closure strategies. Clip cost and LSCP recurrence rate had the greatest and the least impacts on the marginal cost difference, respectively. CONCLUSION : Cold EMR is the dominant strategy over hot EMR, with lower cost and fewer days of lost productivity. In theory, a complete transition to cold EMR for LSCPs in the USA could result in an annual cost saving approaching US$7 million to Medicare beneficiaries.

Delayed Bleeding After Endoscopic Resection of Colorectal Polyps: Identifying High-Risk Patients

Delayed post-polypectomy bleeding (DPPB) is a potentially severe complication of therapeutic colonoscopy which can result in hospital readmission and re-intervention. Over the last decade, rates of DPPB reported in the literature have fallen from over 2% to 0.3–1.2%, largely due to improvements in resection technique, a shift towards cold snare polypectomy, better training, adherence to guidelines on periprocedural antithrombotic management, and the use of antithrombotics with more favourable bleeding profiles. However, as the complexity of polypectomy undertaken worldwide increases, so does the importance of identifying patients at increased risk of DPPB. Risk factors can be categorised according to patient, polyp and personnel related factors, and their integration together to provide an individualised risk score is an evolving field. Strategies to reduce DPPB include safe practices relevant to all patients undergoing colonoscopy, as well as specific considerations for patients identified to be high risk. This narrative review sets out an evidence-based summary of factors that contribute to the risk of DPPB before discussing pragmatic interventions to mitigate their risk and improve patient safety.

Safety and efficacy of cold versus hot snare polypectomy including colorectal polyps ≥1 cm in size

Cold snare polypectomy (CSP; polypectomy without electrocautery) has spread rapidly worldwide during the past decade in what has been called "Cold Revolution". We performed a PubMed literature search for studies investigating CSP outcomes for colorectal polyps. Five randomized controlled trials (RCTs) assessed the complete resection rates (CRRs). The CRRs were similar regardless of the presence or absence of electrocautery, and the efficacy of submucosal injection for better CRRs is still controversial. Eight RCTs assessed the adverse events. The incidence of intraprocedural bleeding with cold procedures was comparable to or higher than that of hot procedures. The incidences of delayed bleeding were comparable to or lower with cold procedures, especially in patients taking anticoagulants. Fifteen studies have been reported on CSP for large (≥1 cm) colorectal polyps (10 retrospective studies, four prospective single-arm studies, and one prospective RCT). These studies reported that the safe cold procedures (a low intra- and post-procedural bleeding rate without perforation) could be implemented for lesions ≥1 cm. However, considering the incision depth of CSP and the local recurrence rate based on the current evidence, only large sessile serrated lesions (SSLs) can be candidates for cold procedures, and large adenomas should not be candidates for this procedure. Based on the current evidence, CSP seems to be the appropriate standard procedure for sub-centimeter colorectal low-grade adenomas due to its safety and simplicity. Thus, large SSLs can be candidates for cold procedures; however, careful inspection and further prospective studies are warranted to confirm the procedure's clinical relevance.

Effectiveness and safety of the different endoscopic resection methods for 10- to 20-mm nonpedunculated colorectal polyps: A systematic review and pooled analysis

BACKGROUND

We performed a systematic review and pooled analysis to assess the effectiveness and safety of different endoscopic resection methods for 10- to 20-mm nonpedunculated colorectal polyps.

METHODS

Articles in PubMed, EMBASE, and the Cochrane Library related to the common endoscopic treatment of 10- to 20-mm nonpedunculated polyps published as of April 2020 were searched. Primary outcomes were the R0 resection rate and en bloc resection rate. Secondary outcomes were safety and the recurrence rate. Meta-regression and subgroup analysis were also performed.

RESULTS

A total of 36 studies involving 3212 polyps were included in the final analysis. Overall, the effectiveness of resection methods with a submucosal uplifting effect, including endoscopic mucosal resection (EMR), cold EMR and underwater EMR (UEMR), was better than that of methods without a nonsubmucosal uplifting effect [R0 resection rate, 90% (95% confidence interval (CI) 0.81-0.94, I² = 84%) vs 82% (95% CI 0.78-0.85, I² = 0%); en bloc resection rate 85% (95% CI 0.79-0.91, I² = 83%) vs 74% (95% CI 0.47-0.94, I² = 94%)]. Regarding safety, the pooled data showed that hot resection [hot snare polypectomy, UEMR and EMR] had a higher risk of intraprocedural bleeding than cold resection [3% (95% CI 0.01-0.05, I² = 68%) vs 0% (95% CI 0-0.01, I² = 0%)], while the incidences of delayed bleeding, perforation and post-polypectomy syndrome were all low.

CONCLUSIONS

Methods with submucosal uplifting effects are more effective than those without for resecting 10- to 20-mm nonpedunculated colorectal polyps, and cold EMR is associated with a lower risk of intraprocedural bleeding than other methods. Additional research is needed to verify the advantages of these methods, especially cold EMR.

Cold versus hot polypectomy/endoscopic mucosal resection-A review of current evidence

Background

Colonoscopy with polypectomy substantially reduces the risk of colorectal cancer (CRC) but interval cancers still account for 9% of all CRCs, some of which are due to incomplete resection.

Aim

The aim of this review is to compare the outcomes of cold and hot endoscopic resection and provide technical tips and tricks for optimizing cold snare polypectomy.

Results

Cold snare polypectomy (CSP) is the standard technique for small (≤10 mm) colorectal polyps. For large colonic polyps (>10 mm), hot resection techniques with use of electrocautery (polypectomy or endoscopic mucosal resection) were recommended until recently. However, the use of electrocoagulation brings serious adverse effects in up to 9% of the patients, such as delayed bleeding, post‐polypectomy syndrome and perforation. In recent years, efforts have been made to improve the polypectomy with cold snare in order to avoid these adverse effects of electrocoagulation without compromising the efficacy of the resection. Several authors have recently shown that the complication rates of CSP of polyps >10 mm is close to zero and recurrence rates varies between 5‐18%. Lower recurrence rates are found in serrated lesions (<8%).

Anticoagulation and antiplatelet management in gastrointestinal endoscopy: A review of current evidence

The role of endoscopic procedures, in both diagnostic and therapeutic purposes is continually expanding and evolving rapidly. In this context, endoscopists will encounter patients prescribed on anticoagulant and antiplatelet medications frequently. This poses an increased risk of intraprocedural and delayed gastrointestinal bleeding. Thus, there is now greater importance on optimal pre, peri and post-operative management of anticoagulant and/or antiplatelet therapy to minimise the risk of post-procedural bleeding, without increasing the risk of a thromboembolic event as a consequence of therapy interruption. Currently, there are position statements and guidelines from the major gastroenterology societies. These are available to assist endoscopists with an evidenced-based systematic approach to anticoagulant and/or antiplatelet management in endoscopic procedures, to ensure optimal patient safety. However, since the publication of these guidelines, there is emerging evidence not previously considered in the recommendations that may warrant changes to our current clinical practices. Most notably and divergent from current position statements, is a growing concern regarding the use of heparin bridging therapy during warfarin cessation and its associated risk of increased bleeding, suggestive that this practice should be avoided. In addition, there is emerging evidence that anticoagulant and/or antiplatelet therapy may be safe to be continued in cold snare polypectomy for small polyps (< 10 mm).