Hot snare polypectomy with or without saline solution/epinephrine lift for the complete resection of small colorectal polyps

Risk factors for post-polypectomy bleeding in patients with end-stage renal disease undergoing colonoscopic polypectomy

BACKGROUND AND AIMS

Little is known about the risk factors of bleeding after colonoscopic polypectomy in patients with end-stage renal disease (ESRD). This study investigated the incidence and risk factors of post-polypectomy bleeding (PPB), including immediate and delayed bleeding, in patients with ESRD.

METHODS

Ninety-two patients with ESRD who underwent colonoscopic polypectomy between September 2005 and June 2020 at a single tertiary referral center were included. The patients' medical records were retrospectively reviewed. Patient- and polyp-related factors associated with immediate PPB (IPPB) were analyzed using logistic regression analysis. Additionally, the optimal cutoff polyp size related to a significant increase in the risk of IPPB was determined by performing receiver operating characteristic (ROC) analysis and calculating the area under the ROC curve (AUC).

RESULTS

In total, 286 polyps were removed. IPPB occurred in 24 (26.1%) patients and 46 (16.1%) polyps and delayed PPB occurred in 2 (2.2%) patients. According to multivariate analysis, the polyp size (> 7 mm), old age (> 70), and endoscopic mucosal resection (EMR) as the polypectomy method (EMR versus non-EMR) were found to be independent risk factors for IPPB. According to the Youden index method, the optimal cutoff polyp size to identify high-risk polyps for IPPB was 7 mm (AUC = 0.755; sensitivity, 76.1%; specificity, 69.6%).

CONCLUSIONS

Colonoscopic polypectomy should be performed with caution in patients with ESRD, especially in those with the following risk factors: advanced age (> 70 years), polyp size > 7 mm, and EMR as the polypectomy method.

Incomplete resection of colorectal polyps of 4-20 mm in size when using a cold snare, and its associated factors

BACKGROUND : Cold snare polypectomy (CSP) is increasingly used for polypectomy and is recommended as the first-line modality for small (< 10 mm) polyps. This study aimed to evaluate incomplete resection rates (IRRs) when using CSP for colorectal polyps of 4-20 mm. METHODS : Adults (45-80 years) undergoing screening, surveillance, or diagnostic colonoscopy and CSP by one of nine endoscopists were included. The primary outcome was the IRR for colorectal polyps of 4-20 mm, defined as the presence of polyp tissue in marginal biopsies after resection of serrated polyps or adenomas. Secondary outcomes included the IRR for serrated polyps, ease of resection, and complications. RESULTS:  413 patients were included (mean age 63; 48 % women) and 182 polyps sized 4-20 mm were detected and removed by CSP. CSP required conversion to hot snare resection in < 1 % of polyps of < 10 mm and 44 % of polyps sized 10-20 mm. The IRRs for polyps < 10 mm and ≥ 10 mm were 18 % and 21 %. The IRR was higher for serrated polyps (26 %) compared with adenomas (16 %). The IRR was higher for flat (IIa) polyps (odds ratio [OR] 2.9, 95 %CI 1.1-7.4); and when resection was judged as difficult (OR 4.2, 95 %CI 1.5-12.1), piecemeal resection was performed (OR 6.6, 95 %CI 2.0-22.0), or visible residual polyp was present after the initial resection (OR 5.4, 95 %CI 2.0-14.9). Polyp location, use of a dedicated cold snare, and submucosal injection were not associated with incomplete resection. Intraprocedural bleeding requiring endoscopic intervention occurred in 4.7 %. CONCLUSIONS : CSP for polyps of 4-9 mm is safe and feasible; however, for lesions ≥ 10 mm, CSP failure occurs frequently, and the IRR remains high even after technical success. Incomplete resection was associated with flat polyps, visual residual polyp, piecemeal resection, and difficult polypectomies.

Endoscopic management of colorectal polyps

Colorectal polyps are premalignant lesions in the lower gastrointestinal tract. Endoscopic polypectomy is an effective strategy to prevent colorectal cancer morbidity and more invasive procedures. Techniques for the endoscopic resection of polyps keep evolving, and endoscopists are required to perform the most appropriate technique for each polyp. In this review, we outline the evaluation and classification of polyps, update the recommendations for optimal treatment, describe the polypectomy procedures and their strengths/weaknesses, and discuss the promising innovative methods or concepts.

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.

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.

Personalizing Polypectomy Techniques Based on Polyp Characteristics

Polypectomy is an essential skill for all endoscopists performing lower gastrointestinal endoscopy. Different polypectomy tools and techniques have evolved and it is important that endoscopists are familiar with these so they can select the most appropriate technique for each polyp. This narrative review updates the different concepts in tailoring polypectomy technique to the characteristics of polyps. Effective polypectomy requires different components, including the following: careful evaluation of the polyp; decision making about optimal polyp management; actual polypectomy, which includes careful positioning of the endoscope and polyp; and postpolypectomy evaluation of the results (for completeness of resection and prophylaxis of complications).

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.

Hot snare polypectomy versus endoscopic mucosal resection for small colorectal polyps: a randomized controlled trial

BACKGROUND AND AIMS

This study was performed to compare endoscopic mucosal resection (EMR) with hot snare polypectomy (HSP) in terms of the complete resection rate and the incidence of adverse events for resecting small (5-10 mm) colorectal polyps.

METHODS

Small colorectal polyps (5-10 mm) with neoplastic features were randomly allocated to either the HSP or EMR group. A submucosal injection was performed prior to hot snaring in the EMR group only. Complete resection was defined as the absence of neoplastic tissue from two additional biopsies of the polypectomy site. R0 resection was defined as the absence of neoplastic tissue at the margin of the resected specimen.

RESULTS

A total of 362 colon polyps from 272 patients were included, and 167 polyps in the HSP group and 155 polyps in the EMR group were analyzed. Between the polypectomy techniques, there was no significant difference in the complete resection rates, which were 96.4% (161/167) in the HSP group and 95.5% (148/155) in the EMR group (P = 0.67). The R0 resection rate in the HSP and EMR groups was significantly different, with 49.7% (83/167) and 74.8% (116/155), respectively (P < 0.001). There was no significant difference in the incidence of adverse events between the two groups.

CONCLUSIONS

The complete resection rates for small (5-10 mm) polyps were not different between HSP and EMR.

TRIAL REGISTRY

ClincialTrials.gov number NCT02239536.

Underwater versus conventional endoscopic mucosal resection for small size non-pedunculated colorectal polyps: a randomized controlled trial : (UEMR vs. CEMR for small size non-pedunculated colorectal polyps)

BACKGROUND

Underwater endoscopic mucosal resection (UEMR) is a recently developed technique and can be performed during water-aided or ordinary colonoscopy for the treatment of colorectal polyps. The objective of this clinical trial was to evaluate the efficacy and safety of UEMR in comparison with conventional endoscopic mucosal resection (CEMR) of small non-pedunculated colorectal polyps.

METHODS

Patients with small size, non-pedunculated colorectal polyps (4-9 mm in size) who underwent colonoscopic polypectomy were enrolled in this multicenter randomized controlled clinical trial. The patients were randomly allocated to two groups, an UEMR group and a CEMR group. Efficacy and safety were compared between groups.

RESULTS

In the intention-to-treat (ITT) analysis, the complete resection rate was 83.1% (59/71) in the UEMR group and 87.3% (62/71) in the CEMR group. The en-bloc resection rate was 94.4% (67/71) in the UEMR group and 91.5% (65/71) in the CEMR group (difference 2.9%; 90% CI - 4.2 to 9.9%), showed noninferiority (noninferiority margin - 5.7% < - 4.2%). No significant difference in procedure time (81 s vs. 72 s, P = 0.183) was observed. Early bleeding was observed in 1.4% of patients in the CEMR group (1/71) and 1.4% of patients in the UEMR group (1/71). None of the patients in the UEMR group complained of postprocedural bloody stool, whereas two patients in the CEMR group (2/64) reported this adverse event.

CONCLUSION

Our results indicate that UEMR is safer and just as effective as CEMR in En-bloc resection for the treatment of small colorectal polyps as such, UEMR is recommended as an alternative approach to excising small and non-pedunculated colorectal adenomatous polyps.

TRIAL REGISTRATION

Clinical Trials.gov, NCT03833492 . Retrospectively registered on February 7, 2019.

Rates of Incomplete Resection of 1- to 20-mm Colorectal Polyps: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Incomplete resection of neoplastic colorectal polyps can result in postcolonoscopy colorectal cancer. We performed a systematic review and meta-analysis to determine the incomplete resection rate (IRR) of colorectal polyps and associated factors.

METHODS

We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL to identify full-text articles that reported IRRs of polyps 1 to 20 mm, published until March 2019. Exclusion criteria were studies of inflammatory bowel disease cohorts, referrals for difficult polypectomy, polyp sizes larger than 20 mm, and endoscopic submucosal resection and/or dissection as polypectomy approaches. IRRs were calculated based on findings from biopsies taken at polypectomy sites or assessments of margins of resected polyps. The primary outcome was IRR for snare removal of polyps 1 to 20 mm. Secondary outcomes included IRR for polyps 1 to 10 mm and 10 to 20 mm, IRR for hot and cold snare removal of polyps 1 to 10 mm and 10 to 20 mm, IRR of snare removal with or without submucosal injection, and IRR for forceps and cold snare removal of polyps 1 to 5 mm.

RESULTS

We identified 6148 reports and used 32 studies, with a total of 9282 polyps, in our quantitative analysis. The IRR for snare removal of polyps 1 to 20 mm was 13.8% (95% confidence interval [CI] 10.3-17.3; 13 studies, 5128 polypectomies). IRRs were 15.9% for snare removal of polyps 1 to 10 mm (95% CI 9.6-22.1; 9 studies, 2531 polypectomies) and 20.8% for snare removal of polyps 10 to 20 mm (95% CI 12.9-28.8; 6 studies, 412 polypectomies). The IRR for hot snare removal of polyps 1 to 10 mm was 14.2% (95% CI 5.2-23.2) vs 17.3% for cold snare polypectomy (95% CI 14.3‒20.3). The IRR for forceps removal of polyps 1 to 5 mm was 9.9% (95% CI 7.1-13.0) vs 4.4% for snare polypectomy (95% CI 2.9-6.1).

CONCLUSIONS

In a systematic review and meta-analysis, we found that colorectal polyps 1 to 20 mm are frequently incompletely resected, and that risk increases for polyps 10 mm or larger. There is no difference in IRRs of cold vs hot snares for polyps 1 to 10 mm. Snare polypectomy should be used over forceps for polyps 1 to 5 mm.

Underwater versus conventional endoscopic resection of nondiminutive nonpedunculated colorectal lesions: a prospective randomized controlled trial (with video)

BACKGROUND AND AIMS

Incomplete resection of colorectal neoplasia decreases the efficacy of colonoscopy. Conventional resection (CR) of polyps, performed in a gas-distended colon, is the current standard, but incomplete resection rates of approximately 2% to 30% for nondiminutive (>5 mm), nonpedunculated lesions are reported. Underwater resection (UR) is a novel technique. The aim of this study was to determine the incomplete resection rates of colorectal lesions removed by UR versus CR.

METHODS

In a randomized controlled trial, patients with small (6-9 mm) and large (≥10 mm) nonpedunculated lesions were assigned to CR (gas-distended lumen) or UR (water-filled, gas-excluded lumen). Small lesions in both arms were removed with a dedicated cold snare. For CR, large lesions were removed with a hot snare after submucosal injection. For UR, large lesions were removed with a hot snare without submucosal injection. Four-quadrant biopsy samples around the resection sites were used to evaluate for incomplete resection.

RESULTS

Four hundred sixty-two eligible polyps (248 UR vs 214 CR) from 255 patients were removed. Incomplete resection rates for UR and CR were low and did not differ (2% vs 1.9%, P = .91). UR was performed significantly faster for lesions ≥10 mm in size (10-19 mm, 2.9 minutes vs 5.6 minutes, P < .0001); ≥20 mm, 7.3 minutes vs 9.5 minutes, P = .015).

CONCLUSIONS

Low incomplete resection rates are achievable with UR and CR. UR is effective and safe with the advantage of faster resection and potential cost savings for removal of larger (≥10 mm) lesions by avoiding submucosal injection. As an added approach, UR has potential to improve the cost-effectiveness of colonoscopy by increasing efficiency and reducing cost while maintaining quality. (Clinical trial registration number: NCT02889679.).

Underwater Endoscopic Mucosal Resection

Although an established standard, conventional endoscopic mucosal resection (EMR) has disseminated despite an absence of studies demonstrating the value of submucosal injection. Several consequences of poorly executed submucosal injection may increase the difficulty and risk of EMR. Underwater EMR (UEMR), an alternative resection method for colonic neoplasms, avoids the need for submucosal injections. In comparison with reported outcomes of EMR, UEMR achieves similar rates of complete resection with comparable safety, with lower rates of recurrence and fewer repeat procedures. UEMR also compares favorably with endoscopic submucosal dissection in terms of procedure time and rates of complete resection, recurrence, and complications.

BEST POLYPECTOMY TECHNIQUE FOR SMALL AND DIMINUTIVE COLORECTAL POLYPS: A SYSTEMATIC REVIEW AND META-ANALYSIS

BACKGROUND

Polypectomy of colorectal polyps is the mainstay of colorectal cancer prevention. Identification of the best polypectomy technique is imperative.

OBJECTIVE

This review aims at comparing efficacy of nine different resection methods for small colorectal polyps (<10 mm).

METHODS

We searched and selected only randomized controlled trials. Primary outcome was complete resection rates of small polyps by histological eradication. Secondary outcomes were: adverse events, retrieval tissue failures rates and duration of procedure.

RESULTS

Eighteen trials including 3215 patients and 5223 polyps were analysed. Overall, cold polypectomy had a significantly shorter time of procedure than hot polypectomy (RD -5.92, 95%CI -9.90 to -1.94, P<0.05), with no statistical difference on complete histological eradication (RD 0.08, 95%CI -0.03 to 0.19, P>0.05). Regarding cold polypectomy techniques, cold snare was found superior to cold forceps on complete and en-bloc resection rates and less time consuming. When comparing endoscopic mucosal resection (EMR) with hot-snare and cold-snare, the latter showed no-inferiority on histological eradication, adverse events or retrieval tissue failure rates.

CONCLUSION

Cold polypectomy is the best technique for resection of small colorectal polyps. Among cold methods, dedicated cold snare was found superior on histological eradication. Cold snare endoscopic mucosal resection might be considered an option for polyps from 5 to 9 mm.

Efficacy and safety of cold versus hot snare polypectomy for resecting small colorectal polyps: Systematic review and meta-analysis

BACKGROUND AND AIM

Safety and effectiveness of cold snare polypectomy (CSP) compared with hot snare polypectomy (HSP) has been reported. The aim of the present study is to carry out a meta-analysis of the efficacy and safety of HSP and CSP.

METHODS

Randomized controlled trials were reviewed to compare HSP with CSP for resecting small colorectal polyps. Outcomes reviewed include complete resection rate, polyp retrieval, delayed bleeding, perforation and procedure time. Outcomes were documented by pooled risk ratios (RR) with 95% confidence intervals (CI) using the Mantel-Haenszel random effect model.

RESULTS

Eight studies were reviewed in this meta-analysis, including 1665 patients with 3195 polyps. Complete resection rate using HSP was similar to CSP (RR: 1.02, 95% CI: 0.98-1.07, P = 0.31). Polyp retrieval after HSP was similar to CSP (RR: 1.00, 95% CI: 1.00-1.01, P = 0.60). Delayed bleeding rate after HSP was higher than after CSP, although not significantly (patient basis: RR: 7.53, 95% CI: 0.94-60.24, P = 0.06; polyp basis: RR: 7.35, 95% CI: 0.91-59.33, P = 0.06). Perforation was not reported in all eight studies. Total colonoscopy time for HSP was significantly longer than CSP (mean difference 7.13 min, 95% CI: 5.32-8.94, P < 0.001). Specific polypectomy time for HSP was significantly longer than CSP (mean difference 30.92 s, 95% CI: 9.15-52.68, P = 0.005).

CONCLUSION

This meta-analysis shows significantly shorter procedure time using CSP compared with HSP. CSP tends toward less delayed bleeding compared with HSP. We recommend CSP as the standard treatment for resecting small benign colorectal polyps.