Cold Versus Hot Snare Polypectomy for Small Colorectal Polyps: A Pragmatic Randomized Controlled Trial
Submit a Comment
Contributors must reveal any conflict of interest. Comments are moderated. Please see our information for authorsregarding comments on an Annals publication.
Visual Abstract. Cold Snare Polypectomy for Small Polyps.
Snare polypectomy is commonly used to remove polyps during colonoscopy. For small to medium polyps, it can be done with (hot) or without (cold) applying electrical cautery. This trial examined whether cold snare is better than hot snare in reducing delayed bleeding after removal of small to medium polyps.
Abstract
Background:
Although cold snare polypectomy (CSP) is considered effective in reducing delayed postpolypectomy bleeding risk, direct evidence supporting its safety in the general population remains lacking.
Objective:
To clarify whether CSP would reduce delayed bleeding risk after polypectomy compared with hot snare polypectomy (HSP) in the general population.
Design:
Multicenter randomized controlled study. (ClinicalTrials.gov: NCT03373136)
Setting:
6 sites in Taiwan, July 2018 through July 2020.
Participants:
Participants aged 40 years or older with polyps of 4 to 10 mm.
Intervention:
CSP or HSP to remove polyps of 4 to 10 mm.
Measurements:
The primary outcome was the delayed bleeding rate within 14 days after polypectomy. Severe bleeding was defined as a decrease in hemoglobin concentration of 20 g/L or more, requiring transfusion or hemostasis. Secondary outcomes included mean polypectomy time, successful tissue retrieval, en bloc resection, complete histologic resection, and emergency service visits.
Results:
A total of 4270 participants were randomly assigned (2137 to CSP and 2133 to HSP). Eight patients (0.4%) in the CSP group and 31 (1.5%) in the HSP group had delayed bleeding (risk difference, −1.1% [95% CI, −1.7% to −0.5%]). Severe delayed bleeding was also lower in the CSP group (1 [0.05%] vs. 8 [0.4%] events; risk difference, −0.3% [CI, −0.6% to −0.05%]). Mean polypectomy time (119.0 vs. 162.9 seconds; difference in mean, −44.0 seconds [CI, −53.1 to −34.9 seconds]) was shorter in the CSP group, although successful tissue retrieval, en bloc resection, and complete histologic resection did not differ. The CSP group had fewer emergency service visits than the HSP group (4 [0.2%] vs. 13 [0.6%] visits; risk difference, −0.4% [CI, −0.8% to −0.04%]).
Limitation:
An open-label, single-blind trial.
Conclusion:
Compared with HSP, CSP for small colorectal polyps significantly reduces the risk for delayed postpolypectomy bleeding, including severe events.
Primary Funding Source:
Boston Scientific Corporation.
Get full access to this article
View all available purchase options and get full access to this article.
Supplemental Material
References
1.
Winawer SJ, Zauber AG, Ho MN, et al; National Polyp Study Workgroup. Prevention of colorectal cancer by colonoscopic polypectomy. N Engl J Med. 1993;329:1977-81. [PMID: 8247072]
2.
Zauber AG, Winawer SJ, O’Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012;366:687-96. [PMID: 22356322] doi: 10.1056/NEJMoa1100370
3.
Gupta N, Bansal A, Rao D, et al. Prevalence of advanced histological features in diminutive and small colon polyps. Gastrointest Endosc. 2012;75:1022-30. [PMID: 22405698] doi: 10.1016/j.gie.2012.01.020
4.
Horiuchi A, Nakayama Y, Kajiyama M, et al. Removal of small colorectal polyps in anticoagulated patients: a prospective randomized comparison of cold snare and conventional polypectomy. Gastrointest Endosc. 2014;79:417-23. [PMID: 24125514] doi: 10.1016/j.gie.2013.08.040
5.
Hsu WF, Chang CY, Chang CC, et al; Colonoscopy Quality Assurance Joint Working Group of Taiwan Colorectal Cancer Screening Program and Digestive Endoscopy Society of Taiwan. Risk of colonoscopy-related complications in a fecal immunochemical test-based population colorectal cancer screening program. Endoscopy. 2022;54:290-298. [PMID: 33271603] doi: 10.1055/a-1328-5126
6.
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. [PMID: 28970290] doi: 10.1136/gutjnl-2017-314215
7.
Fujiya M, Sato H, Ueno N, et al. Efficacy and adverse events of cold vs hot polypectomy: a meta-analysis. World J Gastroenterol. 2016;22:5436-44. [PMID: 27340361] doi: 10.3748/wjg.v22.i23.5436
8.
Rex DK, Anderson JC, Pohl H, et al. Cold versus hot snare resection with or without submucosal injection of 6- to 15-mm colorectal polyps: a randomized controlled trial. Gastrointest Endosc. 2022;96:330-338. [PMID: 35288147] doi: 10.1016/j.gie.2022.03.006
9.
Takeuchi Y, Mabe K, Shimodate Y, et al; Madowazu Study Group. Continuous anticoagulation and cold snare polypectomy versus heparin bridging and hot snare polypectomy in patients on anticoagulants with subcentimeter polyps. A randomized controlled trial. Ann Intern Med. 2019;171:229-237. [PMID: 31307055] doi: 10.7326/M19-0026
10.
Yeh JH, Wang WL, Lin CW, et al. Safety of cold snare polypectomy with periprocedural antithrombotic agents for colorectal polyps: a systematic review and meta-analysis. Therap Adv Gastroenterol. 2022;15:17562848211070717. [PMID: 35173801] doi: 10.1177/17562848211070717
11.
Shinozaki S, Kobayashi Y, Hayashi Y, et al. Efficacy and safety of cold versus hot snare polypectomy for resecting small colorectal polyps: systematic review and meta-analysis. Dig Endosc. 2018;30:592-599. [PMID: 29675857] doi: 10.1111/den.13173
12.
Raad D, Tripathi P, Cooper G, et al. Role of the cold biopsy technique in diminutive and small colonic polyp removal: a systematic review and meta-analysis. Gastrointest Endosc. 2016;83:508-15. [PMID: 26545637] doi: 10.1016/j.gie.2015.10.038
13.
Jegadeesan R, Aziz M, Desai M, et al. Hot snare vs. cold snare polypectomy for endoscopic removal of 4-10mm colorectal polyps during colonoscopy: a systematic review and meta-analysis of randomized controlled studies. Endosc Int Open. 2019;7:E708-E716. [PMID: 31073538] doi: 10.1055/a-0808-3680
14.
Gómez V, Badillo RJ, Crook JE, et al. Diminutive colorectal polyp resection comparing hot and cold snare and cold biopsy forceps polypectomy. Results of a pilot randomized, single-center study (with videos). Endosc Int Open. 2015;3:E76-80. [PMID: 26134778] doi: 10.1055/s-0034-1390789
15.
de Benito Sanz M, Hernández L, Garcia Martinez MI, et al; POLIPEC HOT-COLD Study Group. Efficacy and safety of cold versus hot snare polypectomy for small (5-9mm) colorectal polyps: a multicenter randomized controlled trial. Endoscopy. 2022;54:35-44. [PMID: 33264811] doi: 10.1055/a-1327-8357
16.
Ichise Y, Horiuchi A, Nakayama Y, et al. Prospective randomized comparison of cold snare polypectomy and conventional polypectomy for small colorectal polyps. Digestion. 2011;84:78-81. [PMID: 21494037] doi: 10.1159/000323959
17.
Paspatis GA, Tribonias G, Konstantinidis K, et al. A prospective randomized comparison of cold vs hot snare polypectomy in the occurrence of postpolypectomy bleeding in small colonic polyps. Colorectal Dis. 2011;13:e345-8. [PMID: 21689363] doi: 10.1111/j.1463-1318.2011.02696.x
18.
Suzuki S, Gotoda T, Kusano C, et al. Width and depth of resection for small colorectal polyps: hot versus cold snare polypectomy. Gastrointest Endosc. 2018;87:1095-1103. [PMID: 29122600] doi: 10.1016/j.gie.2017.10.041
19.
Zhang Q, Gao P, Han B, et al. Polypectomy for complete endoscopic resection of small colorectal polyps. Gastrointest Endosc. 2018;87:733-740. [PMID: 28647136] doi: 10.1016/j.gie.2017.06.010
20.
Lee CK, Shim JJ, Jang JY. Cold snare polypectomy vs. cold forceps polypectomy using double-biopsy technique for removal of diminutive colorectal polyps: a prospective randomized study. Am J Gastroenterol. 2013;108:1593-600. [PMID: 24042189] doi: 10.1038/ajg.2013.302
21.
Kim JS, Lee BI, Choi H, et al. Cold snare polypectomy versus cold forceps polypectomy for diminutive and small colorectal polyps: a randomized controlled trial. Gastrointest Endosc. 2015;81:741-7. [PMID: 25708763] doi: 10.1016/j.gie.2014.11.048
22.
Chang LC, Shun CT, Hsu WF, et al. Fecal immunochemical test detects sessile serrated adenomas and polyps with a low level of sensitivity. Clin Gastroenterol Hepatol. 2017;15:872-879.e1. [PMID: 27498176] doi: 10.1016/j.cgh.2016.07.029
23.
Nagtegaal ID, Odze RD, Klimstra D, et al; WHO Classification of Tumours Editorial Board. The 2019 WHO classification of tumours of the digestive system. Histopathology. 2020;76:182-188. [PMID: 31433515] doi: 10.1111/his.13975
24.
Chang LC, Shun CT, Hsu WF, et al. Risk of delayed bleeding before and after implementation of cold snare polypectomy in a screening colonoscopy setting. Endosc Int Open. 2019;7:E232-E238. [PMID: 30705958] doi: 10.1055/a-0810-0439
25.
Reumkens A, Rondagh EJ, Bakker CM, et al. Post-colonoscopy complications: a systematic review, time trends, and meta-analysis of population-based studies. Am J Gastroenterol. 2016;111:1092-101. [PMID: 27296945] doi: 10.1038/ajg.2016.234
26.
Warren JL, Klabunde CN, Mariotto AB, et al. Adverse events after outpatient colonoscopy in the Medicare population. Ann Intern Med. 2009;150:849-57, W152. [PMID: 19528563]
27.
Rutter MD, Nickerson C, Rees CJ, et al. Risk factors for adverse events related to polypectomy in the English Bowel Cancer Screening Programme. Endoscopy. 2014;46:90-7. [PMID: 24477363] doi: 10.1055/s-0033-1344987
28.
Ito A, Suga T, Ota H, et al. Resection depth and layer of cold snare polypectomy versus endoscopic mucosal resection. J Gastroenterol. 2018;53:1171-1178. [PMID: 29516270] doi: 10.1007/s00535-018-1446-2
29.
Takayanagi D, Nemoto D, Isohata N, et al. Histological comparison of cold versus hot snare resections of the colorectal mucosa. Dis Colon Rectum. 2018;61:964-970. [PMID: 29944582] doi: 10.1097/DCR.0000000000001109
30.
Kaltenbach T, Anderson JC, Burke CA, et al. Endoscopic removal of colorectal lesions—recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc. 2020;91:486-519. [PMID: 32067745] doi: 10.1016/j.gie.2020.01.029
31.
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. [PMID: 28212588] doi: 10.1055/s-0043-102569
32.
Rastogi A, Keighley J, Singh V, et al. High accuracy of narrow band imaging without magnification for the real-time characterization of polyp histology and its comparison with high-definition white light colonoscopy: a prospective study. Am J Gastroenterol. 2009;104:2422-30. [PMID: 19584829] doi: 10.1038/ajg.2009.403
33.
Sikka S, Ringold DA, Jonnalagadda S, et al. Comparison of white light and narrow band high definition images in predicting colon polyp histology, using standard colonoscopes without optical magnification. Endoscopy. 2008;40:818-22. [PMID: 18668472] doi: 10.1055/s-2008-1077437
34.
Rastogi A, Early DS, Gupta N, et al. Randomized, controlled trial of standard-definition white-light, high-definition white-light, and narrow-band imaging colonoscopy for the detection of colon polyps and prediction of polyp histology. Gastrointest Endosc. 2011;74:593-602. [PMID: 21802078] doi: 10.1016/j.gie.2011.04.050
35.
Lee KK, Jandorf L, Itzkowitz SH. Diminutive polyps among black and Latino populations undergoing screening colonoscopy: evidence supporting a resect and discard approach. Gastrointest Endosc. 2015;81:728-32. [PMID: 25708761] doi: 10.1016/j.gie.2014.11.036
36.
Hsu WF, Cheng SY, Shun CT, et al. Higher risk of advanced histology in adenoma less than 10 mm in fecal immunochemical test screening: implication for management. J Gastroenterol Hepatol. 2020;35:1738-1745. [PMID: 32187748] doi: 10.1111/jgh.15040
37.
Lieberman D, Moravec M, Holub J, et al. Polyp size and advanced histology in patients undergoing colonoscopy screening: implications for CT colonography. Gastroenterology. 2008;135:1100-5. [PMID: 18691580] doi: 10.1053/j.gastro.2008.06.083
38.
Park SK, Ko BM, Han JP, et al. A prospective randomized comparative study of cold forceps polypectomy by using narrow-band imaging endoscopy versus cold snare polypectomy in patients with diminutive colorectal polyps. Gastrointest Endosc. 2016;83:527-32.e1. [PMID: 26358331] doi: 10.1016/j.gie.2015.08.053
39.
Wei MT, Louie CY, Chen Y, et al. Randomized controlled trial investigating cold snare and forceps polypectomy among small polyps in rates of complete resection: the TINYPOLYP trial. Am J Gastroenterol. 2022;117:1305-1310. [PMID: 35467557] doi: 10.14309/ajg.0000000000001799
40.
Acosta RD, Abraham NS, Chandrasekhara V, et al; ASGE Standards of Practice Committee. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83:3-16. [PMID: 26621548] doi: 10.1016/j.gie.2015.09.035
41.
Rabeneck L, Paszat LF, Hilsden RJ, et al. Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology. 2008;135:1899-1906, 1906.e1. [PMID: 18938166] doi: 10.1053/j.gastro.2008.08.058
Information & Authors
Information
Published In
Annals of Internal Medicine
Volume 176 • Number 3 • March 2023
Pages: 311 - 319
History
Published online: 21 February 2023
Published in issue: March 2023
Keywords
Copyright
© 2023 American College of Physicians.
Authors
Metrics & Citations
Metrics
Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. For an editable text file, please select Medlars format which will download as a .txt file. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
Download article citation data for:
Cold Versus Hot Snare Polypectomy for Small Colorectal Polyps: A Pragmatic Randomized Controlled Trial. Ann Intern Med.2023;176:311-319. [Epub 21 February 2023]. doi:10.7326/M22-2189
Cold Versus Hot Snare Polypectomy for Small Colorectal Polyps: A Pragmatic Randomized Controlled Trial. Ann Intern Med.2023;176:311-319. [Epub 21 February 2023]. doi:10.7326/M22-2189
View More
Login Options:
Purchase
You will be redirected to acponline.org to sign-in to Annals to complete your purchase.
Access to EPUBs and PDFs for FREE Annals content requires users to be registered and logged in. A subscription is not required. You can create a free account below or from the following link. You will be redirected to acponline.org to create an account that will provide access to Annals. If you are accessing the Free Annals content via your institution's access, registration is not required.
Create your Free Account
You will be redirected to acponline.org to create an account that will provide access to Annals.
Comments
0 Comments