Efficacy and safety of three different endoscopic methods in treatment of 6-20 mm colorectal polyps

Splenic rupture following endoscopic mucosal resection: A case report and literature review

RATIONALE

This study aims to highlight the rare but severe complication of splenic rupture following colorectal endoscopic mucosal resection (EMR), advocating for increased vigilance during procedures near the splenic flexure.

PATIENT CONCERNS

We present a case report of a 66-year-old woman who experienced persistent abdominal pain after undergoing EMR for an adenomatous lesion in the distal transverse colon.

DIAGNOSES

The diagnosis of splenic rupture was established following her symptoms and clinical evaluation.

INTERVENTIONS

Active conservative management was implemented after diagnosis.

OUTCOMES

The patient's recovery underscores the importance of prompt diagnosis and careful monitoring.

LESSONS

Although splenic rupture after EMR is extremely rare, it is a serious and potentially life-threatening complication. When obtaining informed consent, it is important to emphasize not only common complications like bleeding and perforation but also the risk of splenic injury. Physicians should select appropriate instruments and carefully adjust the angle and force of needle insertion, avoiding excessively long needles and vertical insertion. The procedure should be performed gently to minimize the risk of splenic rupture. For lesions near the splenic flexure, if postoperative abdominal pain occurs, regardless of left shoulder pain, splenic rupture should be considered, and a computed tomography scan promptly performed. Postoperatively, physicians should closely monitor vital signs and repeatedly check blood counts and coagulation parameters. Treatment should be tailored to the splenic injury's extent and the patient's overall condition, with immediate surgery if necessary. High-risk patients should be regularly followed up and instructed to monitor for physical changes. Endoscopists should remain vigilant during procedures, fully understanding potential complications, and closely monitoring the patient's condition postoperatively. This vigilance is key to preventing severe complications and ensuring optimal outcomes.

Cold Versus Hot Snare Endoscopic Resection of Large Nonpedunculated Colorectal Polyps: Randomized Controlled German CHRONICLE Trial

BACKGROUND & AIMS

Endoscopic mucosal resection (EMR) is standard therapy for nonpedunculated colorectal polyps ≥20 mm. It has been suggested recently that polyp resection without current (cold resection) may be superior to the standard technique using cutting/coagulation current (hot resection) by reducing adverse events (AEs), but evidence from a randomized trial is missing.

METHODS

In this randomized controlled multicentric trial involving 19 centers, nonpedunculated colorectal polyps ≥20 mm were randomly assigned to cold or hot EMR. The primary outcome was major AE (eg, perforation or postendoscopic bleeding). Among secondary outcomes, major AE subcategories, postpolypectomy syndrome, and residual adenoma were most relevant.

RESULTS

Between 2021 and 2023, there were 396 polyps in 363 patients (48.2% were female) enrolled for the intention-to-treat analysis. Major AEs occurred in 1.0% of the cold group and in 7.9% of the hot group (P = .001; odds ratio [OR], 0.12; 95% CI, 0.03-0.54). Rates for perforation and postendoscopic bleeding were significantly lower in the cold group, with 0% vs 3.9% (P = .007) and 1.0% vs 4.4% (P = .040). Postpolypectomy syndrome occurred with similar frequency (3.1% vs 4.4%; P = .490). After cold resection, residual adenoma was found more frequently, with 23.7% vs 13.8% (P = .020; OR, 1.94; 95% CI, 1.12-3.38). In multivariable analysis, lesion diameter of ≥4 cm was an independent predictor both for major AEs (OR, 3.37) and residual adenoma (OR, 2.47) and high-grade dysplasia/cancer for residual adenoma (OR, 2.92).

CONCLUSIONS

Cold resection of large, nonpedunculated colorectal polyps appears to be considerably safer than hot EMR; however, at the cost of a higher residual adenoma rate. Further studies have to confirm to what extent polyp size and histology can determine an individualized approach. German Clinical Trials Registry (Deutsches Register Klinischer Studien), Number DRKS00025170.

Efficacy and Safety of Cold Versus Hot Snare Endoscopic Mucosal Resection in Colorectal Polyp Removal: A Systematic Review and Meta-Analysis

BACKGROUND

Cold snare endoscopic mucosal resection (C-EMR) is hypothesized to offer a safety advantage over hot snare endoscopic mucosal resection (H-EMR). The primary objective of this meta-analysis is to evaluate the effectiveness and safety of C-EMR versus H-EMR for the management of colorectal lesions.

METHODS

A meta-analysis was performed to determine pooled odds ratios (ORs) for comparing outcomes between the C-EMR and H-EMR groups.

RESULTS

The pooled OR for complete resection rates were estimated at 0.70 (95% CI: 0.36-1.36, P =0.29) and en bloc rates were 0.24 (95% CI: 0.05-1.08, P=0.06) between C-EMR group and H-EMR group. The overall complete resection rate for C-EMR was 84%, and the en bloc resection rate was 57. Notably, C-EMR was associated with a significantly lower incidence of delayed bleeding. The recurrence rate of polyps was very low (2%) when treating sessile serrated polyp (SSP) lesions, but higher (23%) for non-SSP lesions. Subgroup analysis revealed minimal recurrence of polyps after using C-EMR for lesions between 10 to 20 mm and ≥20 mm.

CONCLUSIONS

This meta-analysis suggests that C-EMR could be a safer and equally effective alternative to H-EMR for resecting colorectal lesions. We recommend C-EMR as the preferred method for excising large colorectal lesions.

Cold sub-mucosal injection versus traditional cold snare polypectomy for diminutive and small colorectal polyps: A systematic review and meta-analysis

BACKGROUND

The guidelines recommend conventional cold snare polypectomy (C-CSP) for diminutive and small colorectal polyps (≤ 10 mm). However, it remains unclear whether CSP with sub-mucosal injection (SI-CSP) achieves comparable efficacy to C-CSP for managing these lesions. This study compares SI-CSP with C-CSP for patients with diminutive and small colorectal polyps.

METHODS

An electronic literature search was conducted to retrieve articles comparing resection outcomes between SI-CSP and C-CSP in diminutive and small colorectal polyps (registration number INPLASY2023100096). Our primary outcomes of interest were the complete resection rate (CRR), complications (namely immediate bleeding, delayed bleeding and perforation) and polypectomy time. Mean differences with 95% confidence intervals (CI) were employed for continuous variables, while odds ratios (OR) with 95% CI were calculated for categorical variables. Data was analyzed using a random effects model and the I2 test was utilized to assess heterogeneity.

RESULTS

Eight studies involving 1470 patients with 2223 polyps were included in our analysis. The CRR was not significantly higher in the SI-CSP group, with an OR of 95% CI 0.50 (0.22, 1.15). The incidences of immediate bleeding (OR 95% CI 0.60 [0.26-1.40]) and delayed bleeding (OR 95% CI 0.88 [0.32-2.42]) did not differ significantly between the two groups. On average, the mean polypectomy time was 64.75 seconds shorter in the C-CSP group (95% CI, - 102.96 to - 26.53). Notably, no perforation events were reported in the included studies.

CONCLUSIONS

The use of SI-CSP was not superior to C-CSP in managing diminutive and small colorectal polyps and the procedure required significantly more time.

Association between colonic adenoma size and proliferative zone in the crypt

BACKGROUND

We previously reported unusual adenomas with proliferative zones confined to the lower two-thirds of the crypt. The proliferative zones of colorectal adenomas have three patterns: 'lower,' 'superficial' and 'entire'. This study aimed to clarify the characteristics of each adenoma pattern.

METHODS

We investigated 2925 consecutive patients who underwent colonoscopy at our institute. All polyps that were removed were histologically examined using hematoxylin and eosin staining. The location of the proliferative zone was assessed for adenomas. Data were compared using Dunn's and Kruskal-Wallis tests.

RESULTS

Colorectal adenomas with 'lower' proliferative zone often appeared similar to hyperplastic polyps (42.8%), and the frequency was significantly higher than that of adenomas with 'superficial' and 'entire' proliferative zones (p < 0.001). The mean sizes of adenomas were 2.4, 3.0 and 3.9 mm for 'lower,' 'superficial' and 'entire' proliferative zones, respectively. A significant gradual increase was observed. Regarding morphology, the proportion of type 0-I in adenomas with an 'entire' proliferative zone was significantly higher than that in adenomas with 'superficial' proliferative zone (p < 0.001).

CONCLUSION

While colorectal adenomas develop and increase in size, the proliferative zone appears to shift upward and become scattered.

Cold endoscopic mucosal resection versus cold snare polypectomy for colorectal lesions: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Cold resection of colorectal lesions is widely performed because of its safety and effectiveness; however, it remains uncertain whether adding submucosal injection could improve the efficacy and safety. We aimed to compare cold endoscopic mucosal resection (C-EMR) versus cold snare polypectomy (CSP) for colorectal lesions.

METHODS

We performed a systematic review of randomized controlled trials (RCTs) identified from PubMed, Cochrane Library, and Embase. The primary outcome was complete resection. Secondary outcomes were procedure time, en bloc resection, and adverse events (AEs). Prespecified subgroup analyses based on the size and morphology of the polyps were performed. The random-effects model was used to calculate the pooled risk ratio (RR) and mean difference, with corresponding 95%CIs, for dichotomous and continuous variables, respectively. Heterogeneity was assessed using the Cochran Q test and I 2 statistics.

RESULTS

7 RCTs were included, comprising 1556 patients, with 2287 polyps analyzed. C-EMR and CSP had similar risk ratios for complete resection (RR 1.02, 95%CI 0.98-1.07), en bloc resection (RR 1.08, 95%CI 0.82-1.41), and AEs (RR 0.74, 95%CI 0.41-1.32). C-EMR had a longer procedure time (mean difference 42.1 seconds, 95%CI 14.5-69.7 seconds). In stratified subgroup analyses, the risk was not statistically different between C-EMR and CSP for complete resection in polyps<10 mm or ≥10 mm, or for complete resection, en bloc resection, and AEs in the two groups among nonpedunculated polyps.

CONCLUSIONS

The findings of this meta-analysis suggest that C-EMR has similar efficacy and safety to CSP, but significantly increases the procedure time.

PROSPERO

CRD42023439605.

Cold Snare Polypectomy With or Without Submucosal Injection for Endoscopic Resection of Colorectal Polyps: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND AIMS

The impact of submucosal injection during cold snare polypectomy (CSP) remains uncertain. We conducted an evidence-based comparison of conventional CSP (C-CSP) and CSP with submucosal injection (SI-CSP) for colorectal polyp resection.

METHODS

PubMed, Embase, and the Cochrane Library databases were searched for randomized controlled trials (RCTs) comparing C-CSP with SI-CSP. Major outcomes included the rates of complete resection, en bloc resection, polyp retrieval, and adverse events, as well as the duration of polypectomy. Data were analyzed by using a random-effects model.

RESULTS

A total of seven RCTs were included. Complete resection rates for all polyps (RR 0.98; 95% CI 0.93-1.03), polyps ≤ 10 mm (RR 0.99; 95% CI 0.96-1.02) and polyps > 10 mm (RR 0.92; 95% CI 0.69-1.12) were not substantially different between C-CSP and SI-CSP groups. En bloc resection rate (RR 0.93; 95% CI 0.79-1.09) and polyp retrieval rate (RR 1.00; 95% CI 0.99-1.01) were also not significantly different between the two groups. The SI-CSP group required a prolonged polypectomy time than the C-CSP group (SMD - 0.89; 95% CI -1.29 to -0.49). Adverse events were rare in both groups.

CONCLUSIONS

SI-CSP is not an optimal substitute for CSP in the resection of colorectal polyps, particularly diminutive and small polyps.

HOT VERSUS COLD SNARE FOR COLORECTAL POLYPECTOMIES SIZED UP TO 10MM: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

BACKGROUND

Colorectal cancer is the third most common cancer, and prevention relies on screening programs with resection complete resection of neoplastic lesions.

OBJECTIVE

We aimed to evaluate the best snare polypectomy technique for colorectal lesions up to 10 mm, focusing on complete resection rate, and adverse events.

METHODS

A comprehensive search using electronic databases was conducted to identify randomized controlled trials comparing hot versus cold snare resection for polyps sized up to 10 mm, and following PRISMA guidelines, a meta-analysis was performed. Outcomes included complete resection rate, en bloc resection rate, polypectomy, procedure times, immediate, delayed bleeding, and perforation.

RESULTS

Nineteen RCTs involving 8720 patients and 17588 polyps were included. Hot snare polypectomy showed a higher complete resection rate (RD, 0.02; 95%CI [+0.00,0.04]; P=0.03; I 2=63%), but also a higher rate of delayed bleeding (RD 0.00; 95%CI [0.00, 0.01]; P=0.01; I 2=0%), and severe delayed bleeding (RD 0.00; 95%CI [0.00, 0.00]; P=0.04; I 2=0%). Cold Snare was associated with shorter polypectomy time (MD -46.89 seconds; 95%CI [-62.99, -30.79]; P<0.00001; I 2=90%) and shorter total colonoscopy time (MD -7.17 minutes; 95%CI [-9.10, -5.25]; P<0.00001; I 2=41%). No significant differences were observed in en bloc resection rate or immediate bleeding.

CONCLUSION

Hot snare polypectomy presents a slightly higher complete resection rate, but, as it is associated with a longer procedure time and a higher rate of delayed bleeding compared to Cold Snare, it cannot be recommended as the gold standard approach. Individual analysis and personal experience should be considered when selecting the best approach.

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.

[Risk factors for delayed bleeding after intestinal polypectomy in children]

OBJECTIVES

To investigate the clinical characteristics and risk factors of delayed bleeding after intestinal polypectomy in children, and to provide a theoretical basis for clinical surgical intervention of intestinal polyps.

METHODS

A retrospective analysis was conducted on the clinical data of 2 456 children with intestinal polyps who underwent endoscopic high-frequency electrocoagulation loop resection in the Endoscopy Center of Children's Hospital Affiliated to Zhengzhou University from January 2014 to December 2021. According to the presence or absence of delayed bleeding after surgery, they were divided into bleeding group with 79 children and non-bleeding group with 2 377 children. A multivariate logistic regression analysis was used to investigate the risk factors for delayed bleeding. The receiver operating characteristic (ROC) curve was used to investigate the value of various indicators in predicting delayed bleeding.

RESULTS

Of all 2 456 children, 79 (3.22%) experienced delayed bleeding, among whom 5 children with severe delayed bleeding underwent emergency colonoscopy for hemostasis and 74 received conservative treatment, and successful hemostasis was achieved for all children. There were significant differences between the bleeding and non-bleeding groups in age, body mass index, constipation rate, location of lesion, time of endoscopic procedure, resection method (P<0.05). Children with a diameter of polyps of 6-10 mm and >20 mm were more likely to develop delayed bleeding after resection (P<0.05). The multivariate logistic regression analysis showed that endoscopic operation time, polyp diameter, and resection method were significantly associated with delayed bleeding (P<0.05). The ROC curve analysis showed that the endoscopic operation time, polyp diameter, and resection method had a good value in predicting delayed bleeding after intestinal polypectomy, with an area under the ROC curve of 0.706, 0.688, and 0.627, respectively.

CONCLUSIONS

Endoscopic high-frequency electrocoagulation loop resection has a lower incidence of delayed bleeding in children with intestinal polyps, and the endoscopic operation time, polyp diameter, and resection method are closely associated with the occurrence of postoperative delayed bleeding.

Efficacy and Safety of Cold Snare Polypectomy versus Cold Endoscopic Mucosal Resection for Resecting 3-10 mm Colorectal Polyps: Systematic Review and Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

The safety and efficacy of cold snare polypectomy (CSP) compared to those of cold endoscopic mucosal resection (CEMR) have been reported. This meta-analysis compared the efficacy and safety of CEMR and CSP.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched to identify randomized controlled trials comparing the efficacy and safety of CEMR and CSP in removing 3-10 mm polyps. The outcomes assessed included complete resection rate, intraoperative bleeding rate, delayed bleeding rate, perforation, and polyp removal time. The results are reported as risk ratios (RR) and 95% confidence intervals (CIs) derived from a Mantel-Haenszel random-effects model.

RESULTS

Seven studies comprising 1,911 polyps were included in the analysis. The complete resection rate of CEMR was comparable to that of CSP (RR: 1.01, 95% CI: 0.99-1.04, p = 0.32). Comparable results were also demonstrated for intraoperative bleeding rate (polyp-based analysis: RR: 1.22, 95% CI: 0.33-4.43, p = 0.77), delayed bleeding rate (polyp-based analysis: RR: 1.34, 95% CI: 0.44-4.15, p = 0.61), and polyp removal time (mean difference: 28.31 s, 95% CI: -21.40-78.02, p = 0.26). No studies reported cases of perforation.

CONCLUSION

CEMR has comparable efficacy and safety to CSP in removing 3-10 mm polyps. Further randomized controlled trials with long-term follow-up are warranted to compare and validate efficacy.

Cold snare endoscopic mucosal resection for colon polyps: a systematic review and meta-analysis

BACKGROUND

 Cold snare endoscopic mucosal resection (CS-EMR) can reduce the risks associated with electrocautery during colon polyp resection. Data on efficacy are variable. This systematic review and meta-analysis aimed to estimate the pooled efficacy and safety rates of CS-EMR.

METHODS

 We conducted a comprehensive literature search of multiple databases, from inception to March 2023, for studies addressing outcomes of CS-EMR for colon polyps. The weighted pooled estimates with 95 %CIs were calculated using the random effects model. I2 statistics were used to evaluate heterogeneity.

RESULTS

 4137 articles were reviewed, and 16 studies, including 2592 polyps in 1922 patients (51.4 % female), were included. Overall, 54.4 % of polyps were adenomas, 45 % were sessile serrated lesions (SSLs), and 0.6 % were invasive carcinomas. Polyp recurrence after CS-EMR was 6.7 % (95 %CI 2.4 %-17.4 %, I2  = 94 %). The recurrence rate was 12.3 % (95 %CI 3.4 %-35.7 %, I2  = 94 %) for polyps ≥ 20 mm, 17.1 % (95 %CI 4.6 %-46.7 %, I2  = 93 %) for adenomas, and 5.7 % (95 %CI 3.2 %-9.9 %, I2  = 50 %) for SSLs. The pooled intraprocedural bleeding rate was 2.6 % (95 %CI 1.5 %-4.5 %, I2  = 51 %), the delayed bleeding rate was 1.5 % (95 %CI 0.8 %-2.7 %, I2  = 18 %), and no perforations or post-polypectomy syndromes were reported, with estimated rates of 0.6 % (95 %CI 0.3 %-1.3 %, I2  = 0 %) and 0.6 % (95 %CI 0.3 %-1.4 %, I2  = 0 %), respectively.

CONCLUSION

 CS-EMR demonstrated an excellent safety profile for colon polyps, with variable recurrence rates based on polyp size and histology. Large prospective studies are needed to validate these findings.

The efficacy and safety of cold snare polypectomy with submucosal injection for the removal of polyps less than 20 mm in size: a systematic review and meta-analysis

BACKGROUND AND AIM

Neoplastic polyp removal is important for colorectal cancer prevention. Endoscopists have proposed cold snare endoscopic mucosal resection (CS-EMR) as a solution to solve positive cutting edges and postoperative bleeding. However, many controversies regarding its specific performance in practice have been reported. The aim of this pooled analysis was to report the efficacy and safety of CS-EMR.

METHODS

PubMed/Medline, Embase, Google Scholar, and the Cochrane Library searched up to January 2022 to identify studies in which CS-EMR was performed for the removal of colorectal polyps measuring less than 20 mm. The primary outcome was the complete resection rate (CRR), and the secondary outcome was the rate of adverse events.

RESULTS

Eleven studies were included in the final analysis, which included 861 colorectal polyps. The overall CRR with CS-EMR was 96.3% (95% CI, 93.9-98.2%). The early and delayed bleeding rates of CS-EMR were 3.1% (95% CI, 1.2-5.5%) and 1.4% (95% CI, 0.6-2.4%), respectively. There were no statistical significances between CS-EMR and cold snare polypectomy (CSP) in terms of the CRR and adverse events, as well as CS-EMR and hot snare endoscopic mucosal resection (HS-EMR).

CONCLUSIONS

For resecting colorectal polyps measuring ≤20 mm, CS-EMR is an effective attempt. However, compared with CSP and HS-EMR, CS-EMR did not improve the efficiency and safety of polypectomy as expected. Multicenter randomized controlled trials are needed to compare CSP with CS-EMR in the resection of <10 mm polyps and HSP with CS-EMR in the resection of ≥10 mm polyps.

Cold polypectomy techniques for small and diminutive colorectal polyps: a systematic review and network meta-analysis of randomized controlled trials

OBJECTIVE

In the management of small and diminutive polyps, cold polypectomy is favored over electrocautery polypectomy. However, the optimal cold polypectomy technique is still controversial. Hence, this review aims to investigate the most effective cold technique for small and diminutive colorectal polyps.

METHODS

We conducted a systematic review and network meta-analysis synthesizing randomized controlled trials (RCTs) which were retrieved by systematically searching PubMed, EMBASE, Web of Science, SCOPUS, and Cochrane through 10 February 2023. R software, (R version 4.2.0) and meta-insight software were used to pool dichotomous outcomes using risk ratio (RR) presented with the corresponding confidence interval (CI). Our protocol was prospectively published in PROSPERO with ID: CRD42022345619.

RESULTS

Nineteen RCTs with 3649 patients and 4800 polyps were included in our analysis. Cold techniques (cold forceps polypectomy (CFP), jumbo forceps polypectomy (JFP), dedicated cold snare polypectomy (D-CSP), conventional cold snare polypectomy (C-CSP), underwater cold snare polypectomy (U-CSP), and cold snare endoscopic mucosal resection (CS-EMR) were included in our comparative analysis. CFP was less effective in achieving complete histological resection than C-CSP (RR: 1.10 with 95% CI [1.03-1.18]), CS-EMR (RR: 1.12 with 95% CI [1.02-1.23]), D-CSP (RR: 1.17 with 95% CI [1.04-1.32]), and U-CSP (RR: 1.21 with 95% CI [1.07-1.38]). However, the rest of the comparisons showed no difference.

CONCLUSION

CFP is the least effective method for small and diminutive polyps' removal, and any snare polypectomy technique will achieve better results, warranting more large-scale RCTs to investigate the most effective snare polypectomy technique.

Comparing efficacy and factors of postoperative bleeding in endoscopic mucosal resection vs coagulation for intestinal polyps

This study aimed to assess the effectiveness of Endoscopic Mucosal Resection (EMR) and Argon Plasma Coagulation (APC) as therapeutic approaches for intestinal polyps in patients, and to examine the factors associated with postoperative bleeding. This study included 132 patients diagnosed with colorectal polyps (188 polyps) who underwent endoscopic surgery at our hospital between January 2022 and December 2022. Based on the surgical method employed, the patients were divided into 2 groups: EMR (68 cases, 97 polyps) and APC (64 cases, 91 polyps). Comparative analyses were conducted to assess the clinical efficacy, surgery-related indicators, and quality of life the 2 groups. Furthermore, an investigation was carried out to identify the factors associated with postoperative bleeding. The analysis revealed no statistically significant difference in the cure rate of flat and superficial raised polyps between the EMR group and the APC (P > .05). However, it was found that the EMR group exhibited a significantly higher cure rate for subpedunculated and raised-pedunculated polyps compared to the APC group (P < .05). The results of logistics analysis showed that patients with hypertension (OR = 2.876, 95% CI: 1.119-7.393), patients with diabetes (OR = 5.278, 95% CI: 1.388-20.064), patients with hyperlipidemia (OR = 2.594, 95% CI: 1.054-6.380), the polyps of right hemicolon (OR = 2.743, 95% CI: 1.003-7.504), rectal polyps (OR = 5.143, 95% CI: 1.728-7.504), pedunculated polyps (OR = 4.758, 95% CI: 1.322-17.129), adenomatous polyps (OR = 3.152, 95% CI: 1.018-9.757) were independent risk factors for postoperative bleeding in patients with colorectal polyps (P < .05). The findings suggest that for subpedunculated and pedunculated-raised polyps, EMR can be a suitable treatment approach. On the other hand, flat and superficial-raised polyps can be effectively managed with either EMR or APC. The presence of hypertension, diabetes, hyperlipidemia, polyps of the right hemicolon, rectal polyps, pedunculated polyps, and adenomatous polyps has been established as independent risk factors for postoperative bleeding in patients with 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.

Safety and efficacy of cold endoscopic mucosal resection vs conventional endoscopic mucosal resection for treatment of 10-19 mm colorectal polyps

BACKGROUND

Colorectal polyps are important precancerous lesions in colorectal cancer, which require timely endoscopic treatment. For different extents of polyps, different therapies have different efficacy and safety. This study explored the efficacy and safety of two different methods for treating 10-19 mm colorectal polyps, with an aim to provide guidance for clinical treatment of colorectal polyps.

AIM

To compare the safety and efficacy of cold endoscopic mucosal resection (C-EMR) and conventional endoscopic mucosal resection (EMR) in the treatment of 10-19 mm colorectal polyps.

METHODS

A total of 192 patients with 371 colorectal polyps measuring 10-19 mm, who were hospitalized at the First Affiliated Hospital of Huzhou University from January 2021 to December 2022, were included in this study. The patients underwent either C-EMR or conventional EMR for the colorectal polyps. Age, gender, intestinal preparation score, polyp diameter, location, Paris endoscopic classification, histopathological type, complete resection rate, complete histological resection rate, incidence of complications, resection time, number of hemostatic clips used, and postoperative recurrence were compared between the two groups of patients.

RESULTS

There was no significant difference in age, sex, intestinal preparation score, Paris endoscopic classification, histopathological classification, size, location, complete resection rate, or complete histological resection rate between the two groups (P > 0.05). Immediate intraoperative bleeding occurred in 5.5% (10/181) of polyps and 7.4% (7/95) of patients in the C-EMR group, and the corres-ponding percentages in the EMR group were 2.6% (5/190) and 3.1% (3/97); the difference was not statistically significant between the two groups (P > 0.05). Postoperative delayed bleeding occurred in 0.6% (1/181) of polyps and 1.1% (1/95) of patients in the C-EMR group, and the corresponding percentages in the EMR group were 5.8% (11/190) and 7.2% (7/97); the difference was statistically significant between the two groups (P < 0.05). There was no occurrence of delayed perforation during or after surgery in either group. The average resection time was significantly shorter in the C-EMR group than that of the conventional EMR group [(3.15 ± 0.61) min vs (3.46 ± 0.42) min, P < 0.05]. The average number of hemostatic clips used in the C-EMR group was (1.31 ± 0.88), which was significantly less than that of the conventional EMR group (1.65 ± 0.61; P < 0.05). A total of 164 polyps were followed for 9 to 23 mo in the two groups of patients. The total recurrence rate after resection was 2.44%, and the recurrence rate of C-EMR (2.53%) was higher than that of the conventional EMR group (2.35%), but with no statistical significance (P > 0.05).

CONCLUSION

C-EMR and conventional EMR have similar therapeutic effects in the treatment of 10-19 mm colorectal polyps, but C-EMR has a shorter treatment time, lower incidence of delayed bleeding, and higher safety and economic benefit ratio.

Cold resection for colorectal polyps: where we are and where we are going?

INTRODUCTION

Endoscopic resection of colonic precancerous lesions has been demonstrated to significantly decrease colorectal cancer (CRC) incidence and mortality. Among resection techniques, cold snare polypectomy (CSP) has been shown as a highly feasible, effective and safe option and is widely used in clinical practice, being regarded as the first-line technique for removal of small and diminutive colorectal polyps. On the other hand, conventional hot snare polypectomy (HSP) and endoscopic mucosal resection (EMR), namely the gold standard treatments for larger polyps, may be occasionally associated to complications due to electrocautery injury.

AREAS COVERED

To overcome these shortcomings of electrocautery-based resection techniques, in the last few years CSP has been increasingly assessed as a treatment option for additional indications, with a focus on nonpedunculated colorectal polyps ≥10 mm.

EXPERT OPINION

This review aims to present current and widened indications of CSP discussing the latest findings from the most remarkable studies, with an insight into technical issues, novelties and potential advances in the near future.

Endoscopic mucosal resection using cold snare versus hot snare in treatment for 10-19 mm non-pedunculated colorectal polyps: protocol of a non-inferiority randomised controlled study

INTRODUCTION

Cold polypectomy has the advantages of simple operation, less time-consuming and fewer complications. Guidelines have recommended cold snare polypectomy (CSP) to resect small polyps sized ≤5 mm and sessile polyps sized 6-9 mm. However, evidence is scarce regarding cold resection for non-pedunculated polyps sized ≥10 mm. Cold snare endoscopic mucosal resection (CS-EMR) combining CSP and submucosal injection was designed to improve the complete resection rate and reduce adverse events. We hypothesise that CS-EMR is non-inferior to conventional hot snare endoscopic mucosal resection (HS-EMR) in the resection of 10-19 mm non-pedunculated colorectal polyps.

METHODS AND ANALYSIS

This study is a prospective, randomised, open-label, non-inferiority, single-centre trial. Outpatients scheduled to undergo a colonoscopy and present eligible polyps will be randomised to receive either CS-EMR or HS-EMR. The primary endpoint is the complete resection. Considering that HS-EMR of 10-19 mm colorectal polyps will yield a complete resection rate of at least 92% and a non-inferiority margin of -10%, a total of 232 polyps will be included (one-sided α, 2.5%; β, 20%). The analyses are intended to evaluate first non-inferiority (lower limit 95% CI greater than -10% for group difference) and then superiority (lower limit 95% CI>0%) if non-inferiority is achieved. Secondary endpoints include en-bloc resection, the occurrence of adverse events, the use of endoscopic clips, resection time and cost.

ETHICS AND DISSEMINATION

The study has been approved by the institutional review board of the Peking Union Medical College Hospital (No. K2203). All participants in the trial will provide written informed consent. The results of this trial will be published in an open-access way.

TRIAL REGISTRATION NUMBER

NCT05545787.

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.

Colorectal cold snare polypectomy: Current standard technique and future perspectives

It has been shown that resection of adenomatous colorectal polyps can reduce mortality due to colorectal cancer. In daily clinical practice, simpler and safer methods of colorectal polypectomy have been sought to enable endoscopists to resect all detected lesions. Among these, cold snare polypectomy (CSP) is widely used in clinical practice because of its advantages in shortening procedure time, reducing delayed bleeding risk, and lowering treatment costs, while maintaining a similar complete resection rate for lesions smaller than 10 mm when compared to conventional hot snare polypectomy. This review introduces the findings of previous studies that investigated the efficacy and safety of the CSP procedure for nonpedunculated polyps smaller than 10 mm, and describes technical points to remember when practicing CSP based on the latest evidence, including using a thin wire snare specifically designed for CSP, and observing the surrounding mucosa of the resection site with chromoendoscopy or image-enhanced endoscopy to ensure that there is no residual lesion. This review also describes the potential of expanding the indication of CSP as a treatment for lesions larger than 10 mm, those with pedunculated morphology, those located near the appendiceal orifice, and for patients under continuous antithrombotic agent therapy. Finally, the perspective on optimal treatments for recurrent lesions after CSP is also discussed, despite the limited related evidence and data.

Cold snare polypectomy versus cold endoscopic mucosal resection for small colorectal polyps: a multicenter randomized controlled trial

BACKGROUND

Cold snare polypectomy (CSP) is recommended for the resection of small colorectal polyps. However, few studies have investigated the efficacy of cold endoscopic mucosal resection (cold EMR) for small polyps. Thus, the aim of this study was to investigate the efficacy and safety of cold EMR compared with CSP for small colorectal polyps.

METHODS

This was a multicenter, randomized trial conducted in three tertiary centers from January 2018 to February 2021. Patients with polyps sized 6-10 mm were randomized to CSP or cold EMR group. After polypectomy, two additional biopsies were performed to assess the completeness of resection. The primary outcome was complete polyp resection rate. Secondary outcomes were total procedure time and rate of adverse events such as immediate bleeding, delayed bleeding, and perforation.

RESULTS

A total of 444 polyps in 327 patients were assessed and randomly assigned to each group. Of those, 425 polyps were finally analyzed based on pathology results. The complete resection rate was not significantly different between cold EMR and CSP groups (91.9% vs 89.8%, p = 0.24). However, the total procedure time was significantly increased in cold EMR (87.6 s vs. 45.8 s, p < 0.001). The rate of polypectomy adverse events was not significantly different between the two groups. No patient had massive bleeding or perforation.

CONCLUSIONS

There was no difference in complete resection rate or adverse events between CSP and cold EMR. However, CSP reduced the total procedure time.

Progression in clinical application of cold snare resection technique in colorectal polyps

The cold snare resection technique has been recommended by European and American societies and gradually applied in clinical practice. However, due to the operating habits of endoscopists and the insufficient understanding of the cold resection technique, it has not been fully used in colorectal polyps. In this paper, we review the application status of cold snare resection technique, its use in patients treated with antithrombotic drugs, and postoperative histological changes.

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.

Recurrence rates after endoscopic resection of large colorectal polyps: A systematic review and meta-analysis

BACKGROUND

Complete polyp resection is the main goal of endoscopic removal of large colonic polyps. Resection techniques have evolved in recent years and endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR) with margin ablation, cold snare polypectomy (CSP), cold EMR, and underwater EMR have been introduced. Yet, efficacy of these techniques with regard to local recurrence rates (LRRs) vs traditional hot snare polypectomy and standard EMR remains unclear.

AIM

To analyze LRR of large colonic polyps in a systematic review and meta-analysis.

METHODS

MEDLINE, EMBASE, EBM Reviews, and CINAHL were searched for prospective studies reporting LRR or incomplete resection rate (IRR) after colonic polypectomy of polyps ≥ 10 mm, published between January 2011 and July 2021. Primary outcome was LRR for polyps ≥ 10 mm.

RESULTS

Six thousand nine hundred and twenty-eight publications were identified, of which 34 prospective studies were included. LRR for polyps ≥ 10 mm at up to 12 mo’ follow-up was 11.0% (95%CI, 7.1%-14.8%; 15 studies; 4904 polyps). ESD (1.7%; 95%CI, 0%-3.4%; 3 studies, 221 polyps) and endoscopic mucosal resection with margin ablation (3.3%; 95%CI, 2.2%-4.5%; 2 studies, 947 polyps) significantly reduced LRR vs standard EMR without (15.2%; 95%CI, 12.5%-18.0%; 4 studies, 650 polyps) or with unsystematic margin ablation (16.5%; 95%CI, 15.2%-17.8%; 6 studies, 3031 polyps).

CONCLUSION

LRR is significantly lower after ESD or EMR with routine margin ablation; thus, these techniques should be considered standard for endoscopic removal of large colorectal polyps. Other techniques, such as CSP, cold EMR, and underwater EMR require further evaluation in prospective studies before their routine implementation in clinical practice can be recommended.

Cold versus hot snare resection with or without submucosal injection of 6- to 15-mm colorectal polyps: a randomized controlled trial

BACKGROUND AND AIMS

Cold snare resection of colorectal lesions has been found to be safe and effective for an expanding set of colorectal lesions. In this study, we sought to understand the efficacy of simple cold snare resection and cold EMR versus hot snare resection and hot EMR for colorectal lesions 6 to 15 mm in size.

METHODS

At 3 U.S. centers, 235 patients with 286 colorectal lesions 6 to 15 mm in size were randomized to cold snaring, cold EMR, hot snaring, or hot EMR for nonpedunculated colorectal lesions 6 to 15 mm in size. The primary outcome was complete resection determined by 4 biopsy samples from the defect margin and 1 biopsy sample from the center of the resection defect.

RESULTS

The overall incomplete resection rate was 2.4% (95% confidence interval [CI], .8%-7.5%). All 7 incompletely removed polyps were 10 to 15 mm in size and removed by hot EMR (n = 4, 6.2%), hot snare (n = 2, 2.2%), or cold EMR (n = 1, 1.8%). Cold snaring had no incomplete resections, required less procedural time than the other methods, and was not associated with serious adverse events.

CONCLUSIONS

Cold snaring is a dominant resection technique for nonpedunculated colorectal lesions 6 to 15 mm in size. (Clinical trial registration number: NCT03462706.).

Effect of cold snare polypectomy for small colorectal polyps

BACKGROUND

Colorectal cancer remains a considerable challenge in healthcare nowadays. Approximately 60%-80% of colorectal cancer is caused by intestinal polyps, and resection of intestinal polyps has been proved to reduce the incidence of colorectal cancer. The vast majority of intestinal polyps can be found during colonoscopy and removed endoscopically. Therefore, more attention has been paid to the development of endoscopic resection of intestinal polyps. In this study, we compared the efficacy and safety of cold snare polypectomy (CSP) and hot snare polypectomy (HSP).

AIM

To investigate the efficacy and safety of CSP and HSP for colorectal polyps.

METHODS

Between January and December 2020, 301 patients with colorectal polyps 4-9 mm in diameter were treated with endoscopic therapy in our hospital, and were divided into the CSP group (n = 154) and HSP group (n = 147). The operating time, incidence of bleeding and perforation, use of titanium clips, and complete resection rate were compared between the two groups.

RESULTS

We included 249 patients (301 polyps). No differences in gender, age, and polyp size, location, shape and type were observed between the CSP and HSP groups, and the resection rates in these two groups were 93.4% and 94.5%, respectively, with no significant difference. The use of titanium clips was 15.6% and 95.9%, the operating time was 3.2 ± 0.5 min and 5.6 ± 0.8 min, the delayed bleeding rate was 0% and 2.0%, and delayed perforation was 0% and 0.7%, in the CSP and HSP groups, respectively.

CONCLUSION

For sessile colorectal polyps < 10 mm, CSP had the same resection rate of impaired tissue integrity as traditional HSP had. The rate of complications was lower in the CSP group. CSP is a safe and effective method for polypectomy.

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.

Modified endoscopic mucosal resection techniques for treating precancerous colorectal lesions

Endoscopic mucosal resection (EMR) is a technique allowing efficacious and minimally invasive resection of precancerous lesions across the entire gastrointestinal tract. However, conventional EMR, involving injection of fluid into the submucosal space, is imperfect, given the high rate of recurrence of post-endoscopic resection adenoma, especially after piecemeal resection. In light of these observations, modifications of the technique have been proposed to overcome the weakness of conventional EMR. Some of them were designed to maximize the chance of en bloc resection—cap-assisted EMR, underwater EMR, tip-in EMR, precutting, assisted by ligation device—while others were designed to minimize the complications (cold EMR). In this review, we present their modes of action and summarize the evidence regarding their efficacy and safety.

Efficacy of cold endoscopic mucosal resection vs conventional endoscopic mucosal resection in treatment of nonpedunculated colorectal polyps sized 5-10 mm

BACKGROUND

Cold snare polypectomy (CSP) has been gradually applied to remove small colorectal polyps (6-9 mm). Cold endoscopic mucosal resection (EMR) is based on CSP technology combined with submucosal injection of water. Studies have reported that the histological complete resection rate of cold EMR of 6-9 mm colorectal adenoma is significantly better than that of CSP. However, there are few studies on the efficacy of cold EMR vs conventional EMR.

AIM

To compare the efficacy and safety of cold EMR and conventional EMR for 5-10 mm colorectal adenomas.

METHODS

From August 2019 to December 2020, consecutive hospitalized patients who underwent colorectal polypectomy at the Digestive Endoscopy Center of our hospital were screened for eligible polyps. Eligible polyps were randomized to be treated with either cold EMR or conventional EMR according to a random number table (1:1). The histological complete resection rate, immediate postpolypectomy bleeding, and delayed postpolypectomy bleeding were analyzed.

RESULTS

One hundred and eighty-one patients with 195 eligible polyps were included, including 90 patients with 98 polyps in the cold EMR group and 91 patients with 97 polyps in the conventional EMR group. The en bloc resection rate of polyps in the overall population was 98.5%, and there was no perforation. The overall rate of histological complete resection was 91.8% in the cold EMR group and 95.9% in the EMR group (difference: 4.1%; 95%CI: -3.9-12.3). Subgroup analysis by polyp size showed that the histological complete resection rates were 94.6% and 100% for 5-7 mm polyps (difference: 5.4%; 95%CI: -8.3-19.5), and 90.2% and 93.8% for 8-10 mm polyps (difference: 3.6%; 95%CI: -7.8-15.4). The immediate postpolypectomy bleeding rates of the cold EMR and conventional EMR groups were 2.0% and 1.0%, and the delayed postpolypectomy bleeding rates were 0% and 1%, respectively; there was no statistically significant difference between the two groups.

CONCLUSION

Cold EMR is a safe and effective treatment for 5-10 mm colorectal adenoma, with a histological complete resection rate not inferior to that of conventional endoscopic mucosal resection.

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.

Analysis of 234 cases of colorectal polyps treated by endoscopic mucosal resection

BACKGROUND

Colorectal polyps refer to all neoplasms that protrude into the intestinal cavity. Researchers believe that 50%-70% of colorectal cancers originate from adenomatous polyps.

AIM

To investigate the endoscopic morphologic features, pathologic types, and clinical situation; evaluate the efficacy and safety of endoscopic mucosal resection (EMR); and guide clinicians in their daily practice.

METHODS

Two hundred thirty-four patients who underwent EMR in our hospital from January 1, 2018 to December 31, 2019 were recruited. Data including sex, age, endoscopic morphology of the polyps, and pathological characteristics were analyzed among groups.

RESULTS

A total of 295 polyps were resected from the 234 subjects enrolled in the study, of which 4 (1.36%) were Yamada type I. There were 75 (25.42%) type II, 101 (34.24%) type III, and 115 (38.98%) type IV adenomas. Among them, 41 were non-adenomas, 110 were low-risk adenomas, 139 were high-risk adenomas, and 5 were carcinomas. The differences in distribution were not statistically significant, with P values greater than 0.05. The risk of cancer significantly increased for polyps ≥ 1 cm in diameter (c² = 199.825, P = 0.00). Regarding the endoscopic morphological features, congestion, erosion, and lobulation were more common on the surface morphology of high-risk adenomas and cancerous polyps (c² = 75.257, P = 0.00), and most of them were Yamada types III and IV. In all, 6 of the 295 polyps could not be removed completely, with a one-time resection rate of 97.97%. There were two cases of postoperative bleeding and no cases of perforation, with an overall complication rate of 0.09%.

CONCLUSION

Colorectal polyps ranging from non-adenomatous polyps, low-risk adenomas, and high-risk adenomas to adenocarcinomas each has their own endoscopic features, while EMR, as a mature intervention, has good safety and operability and should be promoted clinically, especially at the primary care level.