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Cold Snare Resection of Colorectal Polyps: Updates and Recent Developments

Cold Snare Resection Colorectal Polyps: Updates and Developments

Abstract

Purpose of review

Cold snare polypectomy (CSP) has been emerging as increasingly popular technique for the removal of colorectal polyps with expanding indications with regard to larger polyps. We reviewed the recent literature to provide an overview of the indications, outcomes, and recent developments in the field of CSP.

Recent findings

There are currently 2 major guidelines recommending the use of CSP for 1–9 mm polyps, with one guideline suggesting its use for 10–19 mm polyps. There have been more than 30 published studies reporting on CSP outcomes in various patient populations, mostly in 1–9 mm polyps. Research suggests that CSP is safe and effective for the resections of 1–9 mm polyps, although its safety superiority over hot snare polypectomy (HSP) is not as clear except for patients on anticoagulation and antithrombotic medication. Data on CSP in 10–19 mm polyps is currently lacking; however, some research suggests higher incomplete resection compared to HSP. There is limited data suggesting that CSP could be non-inferior to HSP for 10–15 mm polyps and that hot endoscopic mucosal resection (EMR) could be superior to CSP for larger polyps with regard to recurrence risks. Cold EMR has been emerging as a potentially safe and effective tool for the resection of ≥ 20 mm sessile serrated lesions (SSLs); however, the potentially associated recurrence risk (especially for adenomas) requires further investigation in research studies.

Summary

CSP can be used safely and effectively in 1–9 mm polyps. There is a lack of data on the efficacy and safety of CSP over HSP and conventional EMR for polyps 10–19 mm. Cold EMR seems to be effective and safe in the resection of ≥ 20 mm SSLs. More research is needed to expand the indications of CSP for its use in routine endoscopic removal of ≥ 10 mm polyps.

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Fig. 1

Abbreviations

AGA:

American Gastroenterological Association

CRC:

Colorectal cancer

CSP:

Cold snare polypectomy

EMR:

Endoscopic mucosal resection

ESD:

Endoscopic submucosal dissection

ESGE:

European Society of Gastrointestinal Endoscopy

HSP:

Hot snare polypectomy

IRR:

Incomplete resection rate

IPB:

Intraprocedural bleeding

LR:

Local recurrence rate

SSL:

Sessile serrated lesion

TA:

Tubular adenoma

TVA:

Tubulovillous adenoma

USMSTF:

United States Multi-Society Task Force

References

Papers of particular interest, published recently, have been highlighted as: • of importance •• of major importance

  1. 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.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  2. Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy The National Polyp Study Workgroup. N Engl J Med. 1993;329:1977–81.

    CAS  PubMed  Article  Google Scholar 

  3. 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.e12 Systematic Review and meta-analysis on IRRs for 1-20mm polyps and factors associated with incomplete resection

    PubMed  Article  Google Scholar 

  4. Robertson DJ, Lieberman DA, Winawer SJ, et al. Colorectal cancers soon after colonoscopy: a pooled multicohort analysis. Gut. 2014;63:949–56.

    PubMed  Article  Google Scholar 

  5. Farrar WD, Sawhney MS, Nelson DB, et al. Colorectal cancers found after a complete colonoscopy. Clin Gastroenterol Hepatol. 2006;4:1259–64.

    PubMed  Article  Google Scholar 

  6. Tollivoro TA, Jensen CD, Marks AR, et al. Index colonoscopy-related risk factors for postcolonoscopy colorectal cancers. Gastrointest Endosc. 2019;89:168-176.e3.

    PubMed  Article  Google Scholar 

  7. Kim KO, Huh KC, Hong SP, et al. Frequency and characteristics of interval colorectal cancer in actual clinical practice: a KASID multicenter study. Gut Liver. 2018;12:537–43.

    PubMed  PubMed Central  Article  Google Scholar 

  8. Samadder NJ, Curtin K, Tuohy TMF, et al. Characteristics of missed or interval colorectal cancer and patient survival: a population-based study. Gastroenterology. 2014;146:950–60.

    PubMed  Article  Google Scholar 

  9. J Adler D Toy JC Anderson et al 2019 Metachronous neoplasias arise in a higher proportion of colon segments from which large polyps were previously removed, and can be used to estimate incomplete resection of 10–20 mm colorectal polyps. Clin Gastroenterol Hepatol

  10. Bressler B, Paszat LF, Chen Z, et al. Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. Gastroenterol. 2007;132:96–102.

    Article  Google Scholar 

  11. Morris EJ, Rutter MD, Finan PJ, et al. Post-colonoscopy colorectal cancer (PCCRC) rates vary considerably depending on the method used to calculate them: a retrospective observational population-based study of PCCRC in the English National Health Service. Gut. 2015;64:1248–56.

    PubMed  Article  Google Scholar 

  12. Adler J, Robertson DJ. Interval colorectal cancer after colonoscopy: exploring explanations and solutions. Am J Gastroenterol. 2015;110:1657–64.

    PubMed  Article  Google Scholar 

  13. Rutter MD, Beintaris I, Valori R, et al. World endoscopy organization consensus statements on post-colonoscopy and post-imaging colorectal cancer. Gastroenterol. 2018;155:909-925 e3.

    Article  Google Scholar 

  14. Tappero G, Gaia E, De Giuli P, et al. Cold snare excision of small colorectal polyps. Gastrointest Endosc. 1992;38:310–3.

    CAS  PubMed  Article  Google Scholar 

  15. Dwyer JP, Tan JYC, Urquhart P, et al. A prospective comparison of cold snare polypectomy using traditional or dedicated cold snares for the resection of small sessile colorectal polyps. Endosc International Open. 2017;5:E1062–8.

    Article  Google Scholar 

  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;82:668–75.

    Article  Google Scholar 

  17. J Roberts J Anderson H Pohl 2018 Safety and efficacy of dedicated cold versus standard snares: 488. Official journal of the American College of Gastroenterology | ACG 113:S281-S282.

  18. Schett B, Wallner J, Weingart V, et al. Efficacy and safety of cold snare resection in preventive screening colonoscopy. Endosc Int Open. 2017;5:E580–6.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  19. Djinbachian R, Dube AJ, Durand M, et al. Adherence to post-polypectomy surveillance guidelines: a systematic review and meta-analysis. Endosc. 2019;51:673–83.

    Article  Google Scholar 

  20. 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; 49:270-297Major European guideline recommending best practices for polypectomyMajor European guideline recommending best practices for polypectomy

    Article  Google Scholar 

  21. Kaltenbach T, Anderson JC, Burke CA, et al. Endoscopic removal of colorectal lesions— recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2020;158:1095-1129. Major American guideline recommending best practices for polypectomy

    Article  Google Scholar 

  22. Pohl H, Anderson JC, Aguilera-Fish A, et al. Recurrence of colorectal neoplastic polyps after incomplete resection. Annals of Internal Medicine 2021.

  23. 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.

    PubMed  Article  Google Scholar 

  24. 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.e1.

    PubMed  Article  Google Scholar 

  25. Din S, Ball AJ, Riley SA, et al. A randomized comparison of cold snare polypectomy versus a suction pseudopolyp technique. Endoscopy. 2015;47:1005–10.

    PubMed  Article  Google Scholar 

  26. Gomez 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;3:76–80.

    Google Scholar 

  27. 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.

    PubMed  Article  Google Scholar 

  28. 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. Gastrointestinal Endosc. 2016;83:527-532.e1.

    Article  Google Scholar 

  29. Hirose R, Yoshida N, Murakami T, et al. Histopathological analysis of cold snare polypectomy and its indication for colorectal polyps 10–14 mm in diameter. Dig Endosc. 2017;29:594–601.

    PubMed  Article  Google Scholar 

  30. Komeda Y, Kashida H, Sakurai T, et al. Removal of diminutive colorectal polyps: a prospective randomized clinical trial between cold snare polypectomy and hot forceps biopsy. World J Gastroenterol. 2017;23:328–35.

    PubMed  PubMed Central  Article  Google Scholar 

  31. Matsuura N, Takeuchi Y, Yamashina T, et al. Incomplete resection rate of cold snare polypectomy: a prospective single-arm observational study. Endoscopy. 2017;49:251–7.

    PubMed  Article  Google Scholar 

  32. Chien N-H, Ni M-H, Huang S-H, et al. Cold snare polypectomy vs cold forceps biopsy in endoscopic treatment of colonic small and diminutive polyps—effectiveness and safety in the real world. Advances in Digestive Medicine. 2018;5:127–31.

    Article  Google Scholar 

  33. Hasegawa H, Bamba S, Takahashi K, et al. Efficacy and safety of cold forceps polypectomy utilizing the jumbo cup: a prospective study. Intest Res 2018.

  34. 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;67:1950–7.

    CAS  PubMed  Article  Google Scholar 

  35. Maruoka D, Arai M, Akizue N, et al. Residual adenoma after cold snare polypectomy for small colorectal adenomas: a prospective clinical study. Endoscopy. 2018;50:693–700.

    PubMed  Article  Google Scholar 

  36. 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. Endosc. 2018;50:403–11.

    Article  Google Scholar 

  37. Tutticci NJ, Hewett DG. Cold EMR of large sessile serrated polyps at colonoscopy (with video). Gastrointest Endosc. 2018;87:837–42.

    PubMed  Article  Google Scholar 

  38. Zhang Q, Gao P, Han B, et al. Polypectomy for complete endoscopic resection of small colorectal polyps. Gastrointest Endosc. 2018;87:733–40.

    PubMed  Article  Google Scholar 

  39. Desai S, Gupta S, Copur-Dahi N, et al. A prospective randomized study comparing jumbo biopsy forceps to cold snare for the resection of diminutive colorectal polyps. Surg Endosc 2019.

  40. Huh CW, Kim JS, Choi HH, et al. Jumbo biopsy forceps versus cold snares for removing diminutive colorectal polyps: a prospective randomized controlled trial. Gastrointestinal Endosc 2019.

  41. Mangira D, Cameron K, Simons K, et al. Cold snare piecemeal EMR of large sessile colonic polyps ≥20 mm (with video). Gastrointest Endosc. 2020;91:1343–52.

    PubMed  Article  Google Scholar 

  42. Piraka C, Saeed A, Waljee AK, et al. Cold snare polypectomy for non-pedunculated colon polyps greater than 1 cm. Endosc Int Open. 2017;05:E184–9.

    Article  Google Scholar 

  43. Arimoto J, Chiba H, Ashikari K, et al. Safety and efficacy of cold snare polypectomy for pedunculated (Ip) polyps measuring less than 10 mm in diameter. Int J Colorectal Dis. 2020;35:859–67.

    PubMed  Article  Google Scholar 

  44. Yabuuchi Y, Imai K, Hotta K, et al. Efficacy and safety of cold-snare endoscopic mucosal resection for colorectal adenomas 10 to 14 mm in size: a prospective observational study. Gastrointest Endosc. 2020;92:1239–46.

    PubMed  Article  Google Scholar 

  45. van Hattem WA, Shahidi N, Vosko S, et al. Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods. Gut. 2021;70:1691.

    PubMed  Article  CAS  Google Scholar 

  46. Suresh S, Zhang J, Ahmed A, et al. Risk factors associated with adenoma recurrence following cold snare endoscopic mucosal resection of polyps ≥ 20 mm: a retrospective chart review. Endosc Int Open. 2021;09:E867–73.

    Article  Google Scholar 

  47. Shimodate Y, Itakura J, Takayama H, et al. Impact of submucosal saline solution injection for cold snare polypectomy of small colorectal polyps: a randomized controlled study. Gastrointest Endosc. 2020;92:715-722.e1.

    PubMed  Article  Google Scholar 

  48. 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 Eur Gastroenterol J. 2021;9:370–7.

    Article  Google Scholar 

  49. Barros RA, Monteverde MJ, Dumonceau J-M, et al. Cold snare polypectomy without submucosal injection: safety and efficacy in 615 large serrated lesions. Endosc Int open. 2021;9:E1421–6.

    PubMed  PubMed Central  Article  Google Scholar 

  50. Li D, Wang W, Xie J, et al. Efficacy and safety of three different endoscopic methods in treatment of 6–20 mm colorectal polyps. Scand J Gastroenterol. 2020;55:362–70.

    PubMed  Article  Google Scholar 

  51. Kimoto Y, Sakai E, Inamoto R, et al. Safety and efficacy of cold snare polypectomy without submucosal injection for large sessile serrated lesions: a prospective study. Clin Gastroenterol Hepatol 2020.

  52. Tate DJ, Awadie H, Bahin FF, et al. Wide-field piecemeal cold snare polypectomy of large sessile serrated polyps without a submucosal injection is safe. Endosc. 2018;50:248–52.

    Article  Google Scholar 

  53. Yamamoto T, Suzuki S, Kusano C, et al. Histological outcomes between hot and cold snare polypectomy for small colorectal polyps. Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology Association. 2017;23:246–52.

    Google Scholar 

  54. Djinbachian R, Renteln DV. Endoscopic polypectomy: how should we determine complete resection status? Clin Gastroenterol Hepatol 2020.

  55. Duong A, Pohl H, Djinbachian R, et al. Evaluation of the polyp-based resect and discard strategy: a retrospective study. Endoscopy 2021.

  56. Taghiakbari M, Pohl H, Djinbachian R, et al. The location-based resect and discard strategy for diminutive colorectal polyps: a prospective clinical study. Endoscopy 2021.

  57. Djinbachian R, Dubé AJ, von Renteln D. Optical diagnosis of colorectal polyps: recent developments. Curr Treat Options Gastroenterol. 2019;17:99–114.

    PubMed  Article  Google Scholar 

  58. 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.

    PubMed  Article  Google Scholar 

  59. Gupta S, Lieberman D, Anderson JC, et al. Recommendations for follow-up after colonoscopy and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc. 2020;91:463-485 e5.

    PubMed  PubMed Central  Article  Google Scholar 

  60. Keswani RN, Crockett SD, Calderwood AH. AGA clinical practice update on strategies to improve quality of screening and surveillance colonoscopy: expert review. Gastroenterol. 2021;161:701–11.

    Article  Google Scholar 

  61. Draganov PV, Chang MN, Alkhasawneh A, et al. Randomized, controlled trial of standard, large-capacity versus jumbo biopsy forceps for polypectomy of small, sessile, colorectal polyps. Gastrointest Endosc. 2012;75:118–26.

    PubMed  Article  Google Scholar 

  62. Willems P, Orkut S, Ditisheim S, et al. An international polypectomy practice survey. Scand J Gastroenterol. 2020;55:497–502.

    PubMed  Article  Google Scholar 

  63. Thoguluva Chandrasekar V, Spadaccini M, Aziz M, et al. Cold snare endoscopic resection of nonpedunculated colorectal polyps larger than 10 mm: a systematic review and pooled-analysis. Gastrointest Endosc. 2019;89:929-936.e3.

    PubMed  Article  Google Scholar 

  64. Jegadeesan R, Aziz M, Desai M, et al. Hot snare vs. cold snare polypectomy for endoscopic removal of 4 - 10 mm colorectal polyps during colonoscopy: a systematic review and meta-analysis of randomized controlled studies. Endosc Int Open 2019;7:E708-E716.

  65. Ket SN, Mangira D, Ng A, et al. Complications of cold versus hot snare polypectomy of 10–20 mm polyps: a retrospective cohort study. JGH open : an open access journal of gastroenterology and hepatology. 2019;4:172–7.

    Article  Google Scholar 

  66. Chang L-C, Shun C-T, Hsu W-F, et al. Risk of delayed bleeding before and after implementation of cold snare polypectomy in a screening colonoscopy setting. Endosc Int open. 2019;7:E232–8.

    PubMed  PubMed Central  Article  Google Scholar 

  67. Takeuchi Y, Mabe K, Shimodate Y, et al. Continuous anticoagulation and cold snare polypectomy versus heparin bridging and hot snare polypectomy in patients on anticoagulants with subcentimeter polyps. Ann Intern Med. 2019;171:229–37.

    PubMed  Article  Google Scholar 

  68. 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.

    PubMed  Article  Google Scholar 

  69. Aizawa M, Utano K, Nemoto D, et al. Risk of delayed bleeding after cold snare polypectomy in patients with antithrombotic therapy. Digestive Diseases and Sciences 2021.

  70. Arimoto J, Chiba H, Ashikari K, et al. Safety of cold snare polypectomy in patients receiving treatment with antithrombotic agents. Dig Dis Sci. 2019;64:3247–55.

    CAS  PubMed  Article  Google Scholar 

  71. Ishii T, Harada T, Tanuma T, et al. Histopathologic features and fragmentation of polyps with cold snare defect protrusions. Gastrointest Endosc. 2021;93:952–9.

    PubMed  Article  Google Scholar 

  72. Tutticci N, Burgess NG, Pellise M, et al. Characterization and significance of protrusions in the mucosal defect after cold snare polypectomy. Gastrointest Endosc. 2015;82:523–8.

    PubMed  Article  Google Scholar 

  73. Klein A, Tate DJ, Jayasekeran V, et al. Thermal ablation of mucosal defect margins reduces adenoma recurrence after colonic endoscopic mucosal resection. Gastroenterol. 2019;156:604-613 e3.

    Article  Google Scholar 

  74. Sidhu M, Shahidi N, Gupta S, et al. Outcomes of thermal ablation of the mucosal defect margin after endoscopic mucosal resection: a prospective, international, multicenter trial of 1000 large nonpedunculated colorectal polyps. Gastroenterol. 2021;161:163-170.e3.

    CAS  Article  Google Scholar 

  75. Liu S, Ho SB, Krinsky ML. Quality of polyp resection during colonoscopy: are we achieving polyp clearance? Dig Dis Sci. 2012;57:1786–91.

    PubMed  Article  Google Scholar 

  76. Aslan F, Camcı M, Alper E, et al. Cold snare polypectomy versus hot snare polypectomy in endoscopic treatment of small polyps. Turk J Gastroenterol. 2014;25:279–83.

    PubMed  Article  Google Scholar 

  77. Yamashina T, Fukuhara M, Maruo T, et al. Cold snare polypectomy reduced delayed postpolypectomy bleeding compared with conventional hot polypectomy: a propensity score-matching analysis. Endosc Int Open. 2017;05:E587–94.

    Article  Google Scholar 

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Correspondence to Daniel von Renteln.

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Roupen Djinbachian declares that he has no conflict of interest. Daniel von Renteln is supported by the “Fonds de Recherche du Québec Santé” career development award and has received research funding from ERBE, Ventage, Pendopharm, and Pentax and is a consultant for Boston Scientific and Pendopharm.

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Djinbachian, R., von Renteln, D. Cold Snare Resection of Colorectal Polyps: Updates and Recent Developments. Curr Treat Options Gastro 20, 221–237 (2022). https://doi.org/10.1007/s11938-022-00369-y

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Keywords

  • Colonoscopy
  • Polypectomy
  • Cold snare
  • Serrated polyps