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

Abstract

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.

^‡ Joint first authors

Publication History

Received: 04 February 2021

Accepted after revision: 14 November 2022

Accepted Manuscript online:
14 November 2022

Article published online:
25 July 2023

• References

• 1 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297
• 2 Djinbachian R, von Renteln D. Cold snare resection of colorectal polyps: updates and recent developments. Curr Treat Options Gastroenterol 2022; 20: 221-237
• 3 Willems P, Orkut S, Ditisheim S. et al. Tu1083 Clinical management of colorectal polyps: results of an international survey. Gastrointest Endosc 2019; 89: AB548-AB549
• 4 Kawamura T, Takeuchi Y, Asai S. et al. A comparison of the resection rate for cold and hot snare polypectomy for 4-9 mm colorectal polyps: A multicentre randomised controlled trial (CRESCENT study). Gut 2018; 67: 1950-1957
• 5 Lieberman D, Moravec M, Holub J. et al. Polyp size and advanced histology in patients undergoing colonoscopy screening: implications for CT colonography. Gastroenterology 2008; 135: 1100-1105
• 6 Lieberman DA, Rex DK, Winawer SJ. et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012; 143: 844-857
• 7 Valori R, Rey JF, Atkin WS. et al. European guidelines for quality assurance in colorectal cancer screening and diagnosis. First Edition–Quality assurance in endoscopy in colorectal cancer screening and diagnosis. Endoscopy 2012; 44 (Suppl. 03) SE88-SE105
• 8 Benard F, Barkun AN, Martel M. et al. Systematic review of colorectal cancer screening guidelines for average-risk adults: Summarizing the current global recommendations. World J Gastroenterol 2018; 24: 124-138
• 9 Anderson MA, Ben-Menachem T. ASGE Standards of Practice Committee. et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70: 1060-1070
• 10 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: S3-S43
• 11 Jass JR, Sobin L. Histological typing of intestinal tumours. Berlin: Springer Science & Business Media; 2012
• 12 Pohl H, Srivastava A, Bensen SP. et al. Incomplete polyp resection during colonoscopy-results of the complete adenoma resection (CARE) study. Gastroenterology 2013; 144: 74-80 e71
• 13 Djinbachian R, Iratni R, Durand M. et al. Rates of incomplete resection of 1- to 20-mm colorectal polyps: a systematic review and meta-analysis. Gastroenterology 2020; 159: 904-914 e912
• 14 Tutticci NJ, Hewett DG. Cold EMR of large sessile serrated polyps at colonoscopy (with video). Gastrointest Endosc 2018; 87: 837-842
• 15 Willems P, Orkut S, Ditisheim S. et al. An international polypectomy practice survey. Scand J Gastroenterol 2020; 55: 497-502
• 16 Horiuchi A, Hosoi K, Kajiyama M. et al. Prospective, randomized comparison of 2 methods of cold snare polypectomy for small colorectal polyps. Gastrointest Endosc 2015; 82: 686-692
• 17 Agarwal A, Garimall S, Scott FI. et al. En bloc endoscopic mucosal resection is equally effective for sessile serrated polyps and conventional adenomas. Surg Endosc 2018; 32: 1871-1878
• 18 Han SJ, Jung Y, Cho YS. et al. Clinical effectiveness of submucosal injection with indigo carmine mixed solution for colon endoscopic mucosal resection. Dig Dis Sci 2018; 63: 775-780
• 19 Horiuchi A, Makino T, Kajiyama M. et al. Comparison between endoscopic mucosal resection and hot snare resection of large nonpedunculated colorectal polyps: A randomized trial. Endoscopy 2016; 48: 646-651
• 20 Thoguluva Chandrasekar V, Aziz M, Patel HK. et al. Efficacy and safety of endoscopic resection of sessile serrated polyps 10 mm or larger: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2020; 18: 2448-2455 e2443
• 21 Rex KD, Vemulapalli KC, Rex DK. Recurrence rates after EMR of large sessile serrated polyps, not the same as IRR. Gastrointest Endosc 2015; 82: 538-541
• 22 Yoshida N, Inoue K, Tomita Y. et al. Cold snare polypectomy for large sessile serrated lesions is safe but follow-up is needed: a single-centre retrospective study. United European Gastroenterol J 2021; 9: 370-377
• 23 Hurlstone DP, Cross SS, Drew K. et al. An evaluation of colorectal endoscopic mucosal resection using high-magnification chromoscopic colonoscopy: A prospective study of 1000 colonoscopies. Endoscopy 2004; 36: 491-498
• 24 Kim H-S, Jung HY, Park HJ. et al. Hot snare polypectomy with or without saline solution/epinephrine lift for the complete resection of small colorectal polyps. Gastrointest Endosc 2018; 87: 1539-1547
• 25 Papastergiou V, Paraskeva KD, Fragaki M. et al. Cold versus hot endoscopic mucosal resection for nonpedunculated colorectal polyps sized 6–10 mm: A randomized trial. Endoscopy 2018; 50: 403-411
• 26 Zhang Q, Gao P, Han B. et al. Polypectomy for complete endoscopic resection of small colorectal polyps. Gastrointest Endosc 2018; 87: 733-740
• 27 Yabuuchi Y, Imai K, Hotta K. A novel thin wire snare-assisted en bloc cold snare endoscopic mucosal resection of a colonic adenoma 10-14 mm in size. Dig Endosc 2019; 31: e76-e77
• 28 Pellise M, Burgess NG, Tutticci N. et al. Endoscopic mucosal resection for large serrated lesions in comparison with adenomas: a prospective multicentre study of 2000 lesions. Gut 2017; 66: 644-653
• 29 Tutticci NJ, Hewett DG. Cold EMR of large sessile serrated polyps at colonoscopy (with video). Gastrointest Endosc 2018; 87: 837-842
• 30 Klein A, Tate DJ, Jayasekeran V. et al. Thermal ablation of mucosal defect margins reduces adenoma recurrence after colonic endoscopic mucosal resection. Gastroenterology 2019; 156: 604-613 e603
• 31 von Renteln D, Pohl H. Is ablation of the endoscopic mucosal resection margin the new standard for colorectal polyps?. Gastroenterology 2019; 156: 546-548