Hot Snare Polypectomy Research Articles

S176 Cold Snare Polypectomy in Pedunculated Colorectal Polyps: A Systematic Review and Meta-Analysis

Introduction: Colonoscopy remains an vital tool for colorectal cancer screening and allows for early detection and removal of adenomatous polyps. While several studies have reported on cold snare polypectomy (CSP) and hot snare polypectomy (HSP) in sessile and flat elevated polyps; limited data exists on outcomes in pedunculated polyps. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of CSP for pedunculated polyps. Methods: Multiple databases were searched till June 2022 to identify studies involving the removal of pedunculated polyps with CSP and HSP. (Table) A random effects model was used to calculate outcomes and 95% confidence intervals (CI). Heterogeneity was assessed using I2 test. Our primary goal was to assess pooled rates of immediate and delayed bleeding with CSP. Secondary outcomes included pooled rates of en-bloc & piecemeal resection as well as prophylactic and post resection clipping. Meta-regression was performed to assess if bleeding was affected by polyp location and use of antithrombotics. Results: Six studies including 1025 patients (1,111 polyps with a mean size 4 – 8.5 mm) were analyzed. 116 and 995 polyps were removed with HSP and CSP, respectively. The overall pooled rate of immediate bleeding following CSP was 49.8% (CI 46.8-52.91; I2 98%), which was significantly higher than HSP, RR 7.89 (CI 4.36-14.29; I20%), p< 0.00001 (Figure 1A). The overall pooled rate of delayed bleeding following CSP was 0% (CI 0.00-0.00; I2 0%), which was significantly lower than HSP, RR 0.05 (CI 0.01-0.43; I20%), p=0.006 (Figure 1B). Pooled rate of en-bloc and piecemeal resection with CSP were 99.7% and 0.3%, respectively. Pooled rate of prophylactic clipping and post procedure clipping (to control immediate bleeding) after CSP was 55.3% and 47.2%, respectively. We found no statistical difference in these outcomes when compared to HSP, RR 0.19 (CI 0.01-6.35; I2 85%), p=0.35 and RR 1.73 (CI 0.12-25.5; I2 98%), p=0.69. Meta-regression showed that concurrent use of antithrombotic and/or antiplatelet agents did not have any effect on immediate bleeding following CSP. Right colon polyp location (proximal to the hepatic flexure) significantly correlated with frequency of immediate bleeding. Conclusion: Our analysis shows that CSP is safe and effective for resection of pedunculated colorectal polyps, especially those less than 10 mm in size. While CSP may increase the risk of immediate bleeding, HSP has a higher risk of delayed bleeding.Figure 1.: Forest plots demonstrating the relative risk of immediate (1A) and delayed (1B) bleeding following polypectomy Table 1. - Characteristics of included studies Author, year Study Design Study Country Total Polyps Arimoto, 2022 Prospective, single center Japan 114 Fatima, 2022 Prospective, single center United States 239 Kaltenbach, 2019 Retrospective, multicenter United States 94 Arimoto, 2021 Retrospective, single center Japan 188 Kudo 2021 Retrospective, single center Japan 444 Arimoto, 2020 Retrospective, single center Japan 90 Kaltenbach, 2019 Retrospective, multicenter United States 94

S2272 Inlet Patch Polyp Mimicking Esophageal Cancer

Introduction: Heterotopic gastric mucosa (HGM) in the proximal esophagus also known as cervical inlet patch is a prevalent accidental finding during EGD. Case Description/Methods: 56 y.o. female with no prior PMH presented with a 4-year history of constipation, heartburn, epigastric pain, and weight loss. Symptoms were not controlled with the PPI trial. EGD showed 2 areas of gastric mucosa heterotopy in the duodenal bulb, sized up to 5 mm. In the cervical esophagus, an area of HGM sized 15x20 mm with protruding lesion Paris 0-Is sized 5x7mm was visualized. In the narrow-band imaging, the vessel pattern was irregular, with dilated interpupillary loops, and an irregular surface pattern. Malignancy was suspected with biopsies obtained. Pathology showed gastric-type epithelium with active inflammation, erosion, and hyperplastic polyp in HGM. On repeat EGD lesion was completely removed with hot snare polypectomy. Final pathology showed inflammatory (granulation) polyp without dysphasia or neoplastic process. The patient’s dyspeptic symptoms improved on follow-up with double dose PPI (Figure). Discussion: HGM is found in up to 10% of the general population. Some studies consider that HGM is a common benign finding which can be used as a surrogate marker for thorough esophagus examination. Other data suggest that inlet patches can be associated with reflux and dysphagia symptoms, dysplasia, and malignancy in rare cases. Quick insertion and withdrawal of the scope can lead to missed diagnoses of HGM and its complications. HGM detection rate can serve as an EGD quality indicator. Narrow band imaging can be used to improve the HGM detection rate. Various classifications of surface and vessel patterns are used to identify squamous cell malignancy in the upper esophagus, but they are inapplicable in HGM. Careful examination with histopathological examination of biopsies is recommended for mucosal abnormalities in HGM.Figure 1.: Narrow-band image of the HGM polyp.

S2133 Suck and Snare: A Technique for Rapid, Complete, and Safe Cold Snare Polypectomy of Sessile Polyps Greater Than One Centimeter

Introduction: Snare polypectomy of flat colon polyps may be challenging when boarders are indistinct or if the snare wire slides over the flat mucosal surface as the snare closes. Current guidelines suggest cold or hot snare polypectomy with or without submucosal injection for the removal of polyps between 1 and 1.9 centimeters (cm). Injection lift polypectomy and hot snare endoscopic mucosal resection of flat lesions can be time intensive and carries risks of perforation, post polypectomy syndrome, and bleeding. Cold snare technique has become increasingly utilized for Paris class 1s and 1sp polyps of any size. We propose an adaptation of the “suction polypectomy technique,” previously described for the removal of less than 1 cm sessile polyps, for use in cold snare polypectomy of sessile polyps greater than 1 cm. Case Description/Methods: Technique: Olympus high definition colonoscopes (CF-HQ190L/I) were used to identify sessile polyps between 10-15 mm (Table). The snare was passed though the instrument and pulled back slightly into the channel. Polyps were then suctioned using the tip of endoscope for 1-2 seconds. This technique was repeated over the surface of the entire lesion until the polyps puckered up, developing a more polypoid shape. The polyps were then immediately resected via cold snare polypectomy (Figure). All polyps were completely resected and there were no procedural complications. Discussion: This series shows that the “suction polypectomy” technique using a cold snare for polyps 1 cm or greater is feasible and safe with the benefits of not requiring the use of lifting agents, injection needles, or significant technical expertise. Future studies are required to determine the feasibility of suction polypectomy in lesions greater than 1.5 cm and the safety and efficacy of the technique in larger prospective cohorts.Figure 1.: Endoscopic images of the technique. Images labeled “A” show the polyp before suction. Images labeled “B” show the polyp after suction. Images labeled “C” show post-polypectomy. Table 1. - Characteristics of Polyps Removed Patient # Polyp Size Location Pathology Diagnosis En Bloc versus Piecemeal Complications (Immediate/Delayed Bleeding or Perforation) 1 10 mm Descending Colon Tubular Adenoma in Fragments En Bloc None 2 10 mm Ascending Colon Sessile Serrated Adenoma En Bloc None 3 12 mm Ascending Colon Sessile Serrated Adenoma En Bloc None 4 12 mm Ascending Colon Tubular Adenoma in Fragments En Bloc None 5 11 mm Transverse Colon Tubular Adenoma En Bloc None

S1571 Device-Assisted Enteroscopy (DAE) in the Surveillance of Intestinal Polyposis in Peutz-Jeghers Syndrome

Introduction: Peutz-Jeghers Syndrome (PJS) is an autosomal dominant, genetic disorder characterized by the formation of hamartomatous polyps in the gastrointestinal tract. These polyps are a source of significant morbidity and mortality in this population due to associated complications of intestinal obstruction, bleeding, and malignant transformation. Surveillance of intestinal polyposis in patients with PJS has not been extensively studied, although centers which perform a significant volume of device-assisted enteroscopies (DAEs) encounter multiple cases each year. With the progressive adoption of DAE, examination of the deep small bowel for monitoring and prophylactic polypectomy has the potential to prevent complications of PJS and minimize the need for repeated laparotomy. Methods: After obtaining IRB approval, electronic health records were used to identify all DAEs performed on patients with PJS at 3 US referral centers (LSU, Duke, and UMass) between January 1, 2007 and January 1, 2020. Electronic medical records were reviewed to collect and analyze multiple data points. Primary endpoints included the complications associated with DAE performed for removal of intestinal hamartomas and the rate of laparotomy in PJS patients prior to and after index DAE. Secondary data points included patient characteristics, procedural details, and size/location/distribution of small bowel hamartomas. Results: Twenty-four patients met our inclusion criteria. Of these, 18 (75%) had previously undergone small bowel surgery for complications related to small bowel hamartomas. Between 2007 - 2020, a total of 46 DAEs were performed in these patients with an average of one surveillance exam every 2.5 years. A total of 131 polypectomies were performed during our study period with an observed complication rate of 1.5%, including one bowel perforation requiring surgery. Only one patient underwent surgery related to small bowel hamartomas following initial DAE surveillance exam over a total of 366 years of aggregated follow-up (Figure). Conclusion: Endoscopic management of small bowel polyps in patients with PJS using DAE is an effective strategy for prophylactic removal of hamartomas. DAE surveillance and endoscopic polypectomy is safe and may decrease the need for repeated laparotomy due to complications from intestinal hamartomas in patients with PJS.Figure 1.: Hamartomatous polyp in the ileum removed with saline injection-lift technique and hot snare polypectomy

S2024 Elderly Patient, Youthful Pathology: Solitary Colonic Juvenile Polyp Found in a 75-Year-Old Male

Introduction: Colonic juvenile polyps are generally found in the pediatric population. Classically, juvenile polyps (JP) are the most common polyp subtype seen in pediatric gastroenterology, accounting for approximately 80-90% of polyps in children. Generally, JP are diagnosed within the first decade of life and most common presentation is painless rectal bleeding. Other terminology used are juvenile hamartomatous polyp or retention polyps. There is no malignant potential for solitary JP and they tend to not recur. Case Description/Methods: We present a 75-year-old male with past medical history of hypertension, diabetes and hyperlipidemia referred to gastroenterology for surveillance colonoscopy due to a history of tubular adenomas. At the pre-procedure visit, the patient was well without GI complaints such as overt bleeding, change in bowel habits or unintentional weight loss. No family history of colon cancer or polyps was reported. Physical exam and vitals were normal at the time of procedure. Colonoscopy revealed a 40mm pedunculated sigmoid colon polyp which was excised using an endoloop at the stalk base followed by hot snare polypectomy ((Figure A). Three other sub-centimeter sessile polyps in the rectosigmoid area were removed by cold snare polypectomy. Histopathological examination of the large pedunculated polyp was consistent with a JP(Figure B). Other polyps were tubular adenomas. Discussion: Our current patient is the oldest reported case of isolated colonic JP. These polyps tend to have a common phenotypical appearance measuring around 10-30mm and roughly 90% of them are considered pedunculated. JP are ultimately defined by their distinctive histopathological features such as edematous lamina propria with inflammatory cells, cystically dilated glands that are bordered by cuboidal or columnar epithelium with reactive changes, and mucus filled glands. Fortunately for our patient, the presence of only a solitary colonic JP generally carries no known malignant potential. Juvenile polyposis syndrome (JPS) on the other hand is a hereditary condition characterized by the presence of hamartomatous polyps in the digestive tract and is known to have an increased risk of digestive tract malignancies. JPS is suspected when a patient has 5 or more juvenile polyps in the gastrointestinal tract or a juvenile polyp and a family history of juvenile polyps. A DNA test to check SMAD4 or BMPR1A gene is helpful.Figure 1.: (a) A 40mm polyp (Paris 0-Ip) located in the in the sigmoid colon. (b) Hamartomatous polyp has ulcerated surface with benign dilated glands.

S1786 Pancreatic Metastasis Secondary to the Masters of Costumes, Renal Cell Carcinoma

Introduction: Renal cell carcinoma (RCC) has been one of the most studied cancers, and its metastatic capabilities are well documented in literature. RCC accounts for 80%-85% of primary renal neoplasm. Approximately 25% of individuals have distant metastases at the time of diagnosis. Its metastatic capabilities continue to be one of the most challenging aspects of the disease. Metastasis to the pancreas has been described in about 2%-5% of all malignant pancreatic tumors. Case Description/Methods: Case of an 80-year-old man with medical history of Stage IV RCC, treated with immunotherapy. Treatment was discontinued due to adverse effects. Patient presents to the ER with a complaint of intractable pruritus. On laboratory values, found with elevated liver enzymes and total bilirubin, with a mixed hepatocellular and cholestatic pattern, reason why gastroenterology service was consulted. Physical examination showed generalized jaundice. Abdominal CT scan showed multiple intrabdominal lesions, including in the pancreas, causing intra and extrahepatic ductal dilation. MRCP showed multiple intrabdominal masses encasing the common bile duct, causing intra and extrahepatic biliary tree and distal pancreatic duct dilation. Concern of a primary pancreaticobiliary malignancy arose. On EGD, multiple gastric and duodenal clean base ulcers and 2 large pedunculated polyps in the second portion of the duodenum removed using hot snare polypectomy technique, and random biopsies on gastric and duodenal ulcers taken. On EUS, a large hyperechoic vascular lesion was observed in the pancreatic head, infiltrating the intrapancreatic bile duct. Another large 3.3 cm x 3.0 cm vascular mass at the gastro-hepatic ligament was observed. Biopsies from duodenal ulcer, duodenal polyp, and pancreatic mass were consistent with metastatic clear cell neoplasm as seen in RCC. ERCP was made to place a fully covered metallic stent at CBD stricture caused by extrinsic compression. Discussion: RCC is the most common renal tumor. Up to 25% of cases present with advanced disease at diagnosis. Our patient presents with multiple intrabdominal masses causing biliary tree and pancreatic duct obstruction. Advanced endoscopic techniques and cross-sectional images play an essential role in the diagnosis and management of pancreaticobiliary pathologies. Other etiologies such as metastatic RCC may mimic primary pancreaticobiliary malignancies. In this case, advanced endoscopic modalities were used for tissue diagnosis and management of metastatic disease.

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.

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

BACKGROUNDComplete 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. AIMTo analyze LRR of large colonic polyps in a systematic review and meta-analysis.METHODSMEDLINE, 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. RESULTSSix 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). CONCLUSIONLRR 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.

Effect of cold snare polypectomy for small colorectal polyps.

BACKGROUNDColorectal 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).AIMTo investigate the efficacy and safety of CSP and HSP for colorectal polyps.METHODSBetween 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.RESULTSWe 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.CONCLUSIONFor 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.

Adoption of Optimal Small (6-9mm) Colorectal Polyp Resection Technique Over Time.

Cold snare polypectomy (CSP) is the preferred resection technique for small (6-9mm) polyps due to lower rate of incomplete resection compared to cold forceps polypectomy (CFP) and improved safety profile over hot snare polypectomy (HSP). To describe resection techniques for small (6-9mm) polyps and determine factors associated with sub-optimal technique. This was retrospective cohort study of colonoscopies performed by gastroenterological and surgical endoscopists from 2012 to 2019 where at least one 6-9mm polyp was removed. Patient, provider, and procedure characteristics were collected. Univariate and multivariate regression analyses were performed to determine factors associated with sub-optimal technique. In total, 773 colonoscopies where 1,360 6-9mm polyps removed by 21 endoscopists were included. CSP was used for 1,122 (82.5%), CFP for 61 (4.5%), and HSP for 177 (13.0%). Surgeon specialty was associated with CFP use (aOR 7.81; 95% CI 3.02-20.16). Polyp location in left colon (aOR 1.65; 95% CI 1.17-2.33) and pedunculated morphology (aOR 12.76; 95% CI 7.24-22.50) were associated with HSP. There was a significant increase in overall CSP use from 30.4% in 2012 to 96.8% in 2019. 82.5% of all 6-9mm polyps removed from 2012 to 2019 were removed using a cold snare with significant increase in CSP from 2012 to 2019. Differences in how optimal technique was adopted over time based on specialty highlight the need for standardized practice guidelines and quality monitoring.

Comparison of cold snare and hot snare polypectomy for the resection of sporadic nonampullary duodenal adenomas

Nonampullary duodenal adenomas can undergo malignant transformation, making endoscopic resection, often by hot snare (HSP) or cold snare polypectomy (CSP), necessary. Although CSP has been shown to be safer for removal of colon polyps, data comparing these techniques for the resection of duodenal adenomas are limited. Our aim was to compare the safety and efficacy of CSP and HSP for the removal of nonampullary duodenal adenomas. We performed a retrospective cohort study of patients referred to 2 academic medical centers with a histologically confirmed sporadic, nonampullary duodenal adenoma who underwent endoscopic snare polypectomy between January 1, 2007 and March 1, 2021. Patients with underlying polyposis syndromes were excluded. Outcomes included postprocedural adverse events and polyp recurrence. Of 110 total patients, 69 underwent HSP and 41 underwent CSP. Intraprocedural bleeding was similar between both groups, but 7 patients in the HSP group experienced delayed adverse events versus none in the CSP group (P= .04). Fifty-four patients had complete polyp resection and subsequent surveillance endoscopies. Multivariate analysis showed polyp size to be associated with recurrence (permm; odds ratio, 1.11; 95% confidence interval, 1.04-1.20; P< .01). Endoscopic resection technique (HSP vs CSP) was not a predictor of recurrence (P= .18). HSP led to more delayed adverse events compared with CSP, whereas no significant differences on outcomes were noted, suggesting that CSP is equally effective and potentially safer for the removal of duodenal adenomas.

Resection depth for small colorectal polyps comparing cold snare polypectomy, hot snare polypectomy and underwater endoscopic mucosal resection.

Background and study aims Small colorectal polyps are removed by various methods, including cold snare polypectomy (CSP), hot snare polypectomy (HSP), and underwater endoscopic mucosal resection (UEMR), but the indications for using these methods are unclear. We retrospectively assessed the efficacy of CSP, HSP, and UEMR for small polyps, focusing on the depth of the resected specimens. Patients and methods Outpatients with non-pedunculated small polyps (endoscopically diagnosed as 6 to 9 mm), resected by two endoscopists between July 2019 and September 2020, were enrolled. We histologically evaluated the specimens resected via CSP, HSP, and UEMR. The main outcome was the containment rate of the muscularis mucosa (MM) and submucosa (SM) tissues. Results Forty polyps resected via CSP (n = 14), HSP (n = 12), or UEMR (n = 14) were enrolled after excluding 13 polyps with resection depths that were difficult to determine. The rates of specimens containing MM and SM tissue differed significantly (57 % and 29 % for CSP, 92 % and 83 % for HSP, and 100 % and 100 % for UEMR, respectively ( P = 0.005 for MM and P < 0.001 for SM tissue). Multiple logistic regression analysis showed UEMR was an independent factor relating to the containment of SM tissue. The thickness of SM tissue by CSP, HSP, and UEMR were 52 μm, 623 μm, and 1119 μm, respectively ( P < 0.001). The thickness by CSP was significantly less than those by HSP and UEMR ( P < 0.001, Bonferroni correction). Conclusions UEMR could be the best method to contain SM tissue without injection. Further studies are needed to evaluate the indication of UEMR for small polyps.

Endoscopic follow-up of mucosal defect after hot versus cold snare polypectomy in animal model.

Cold snare polypectomy (CSP) has received increasing attention in recent years, but few studies have assessed defect repair after polypectomy. Therefore, we compared the repair of mucosal defect after CSP and hot snare polypectomy (HSP) in a rabbit model. Resection of normal colonic mucosa using both HSP and CSP were performed in 40 male New Zealand white rabbits by an experienced endoscopist. Follow-up colonoscopy was performed after 7 and 15days by another endoscopist. We assessed mucosal defect repair, status of healing, scar formation, and intraoperative or delayed complications (including perforation and bleeding). Eight animals died of intraoperative or delayed perforation; follow-up colonoscopy was performed in 32 animals. On follow-up colonoscopy at 7days after operation, 78.1% cases in the CSP group showed healing of mucosal defect compared with none in the HSP group (P<0.001); mucosal repair score in the CSP group was significantly higher than HSP group (P<0.001). On follow-up colonoscopy at 15days, mucosal defect after CSP had completely healed in all cases (100%) versus 96.9% after HSP (P=0.313). Among these healed defects, scar formation was observed in 2 of 32 cases in the CSP group compared with 19 of 31 in the HSP group (P<0.001). Intraoperative perforation rate was significantly higher in the HSP group (15% vs 2.5%; P=0.048). Mucosal defect repair after CSP is quicker compared with HSP and is more likely to result in scarless healing. HSP is more likely to cause perforation in the thin colon walls.

A30 RECURRENCE RATES AFTER ENDOSCOPIC RESECTION OF LARGE COLORECTAL POLYPS: A SYSTEMATIC REVIEW AND META-ANALYSIS

BackgroundComplete polyp resection is the main goal of endoscopic removal of large colonic polyps. Resection techniques used for their removal have evolved in recent years and endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR) with margin ablation, cold snare polypectomy (CSP), cold snare EMR and underwater EMR have been introduced. Yet, efficacy of these techniques with regard to local recurrence rates (LRR) compared to traditional hot snare polypectomy (HSP) and standard EMR remains unclear.AimsWe aimed to analyze LRR of large colonic polyps in a systematic review and meta-analysis.MethodsMEDLINE, EMBASE, EBM Reviews, and CINAHL databases were searched to identify 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.Results6928 publications were identified, of which 34 prospective studies were included into the analysis. LRR for polyps >10 mm at follow-up (FU) up to 12 months was 11.0% (95% CI 7.1–14.8; 15 studies; 6259 polyps). ESD (1.7%; 95% CI 0–3.4; 3 studies, 221 polyps) and EMR with margin ablation (3.3%; 95% CI 2.2–4.5; 2 studies, 947 polyps) significantly reduced LRR compared to 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, 3183 polyps).ConclusionsLocal polyp recurrence after standard EMR of large colonic polyps is high. LRR is significantly lower after ESD or EMR with routine margin ablation, so that these techniques should be considered standard for endoscopic removal of large colorectal polyps. CSP, cold snare EMR and underwater EMR should only be used within clinical trials until more high-quality data regarding LRR becomes available. Funding AgenciesNone

Influence of early colorectal cancer component on the positive margins after endoscopic resection: a retrospective study

BackgroundEndoscopic treatment methods for early colorectal cancer (ECRC) mainly depend on the size and morphology. It is unclear whether different endoscopic resection methods could achieve curative resection for ECRC confined in the mucosa. The study was designed to compare the rate of positive vertical margin (VM) of ECRC with advanced adenomas (AAs) including adenoma > 1 cm, villous adenoma, high-grade intraepithelial neoplasia/dysplasia stratified by different endoscopic resection methods.MethodsRate of positive VM for 489 ECRCs including Intramucosal (pTis) and superficial submucosal invasion (pT1) carcinomas were compared with those of 753 AAs stratified by different endoscopic resection methods using Chi-squared test. Multivariate logistic model was performed to investigate the risk factors of positive VM for different endoscopic resection methods.ResultsThe pTis ECRC exhibited a similar rate of positive VM as that of AAs for en bloc hot snare polypectomy (HSP, 0% Vs. 0.85%, P = 0.617), endoscopic mucosal resection (EMR, 0.81% vs. 0.25%, P = 0.375) and endoscopic submucosal dissection (ESD, 1.82% Vs. 1.02%, P = 0.659). The pTis carcinoma was not found to be a risk factor for positive VM by en bloc EMR (P = 0.349) or ESD (P = 0.368). The en bloc resection achieved for pT1a carcinomas exhibited similar to positive VM achieved through ESD (2.06% Vs. 1.02%, P = 1.000) for AAs. Nonetheless, EMR resulted in higher risk of positive VM (5.41% Vs. 0.25%, P < 0.001) for pT1a carcinomas as compared to AAs. The pT1a invasion was identified as a risk factor for positive VM in polyps with en bloc EMR (odds ratio = 23.90, P = 0.005) but not ESD (OR = 2.96, P = 0.396).ConclusionCollectively, the pTis carcinoma was not found to be a risk factor for positive VM resected by en bloc HSP, EMR or ESD. Additionally, ESD may be preferred over EMR for pT1a carcinomas with lower rate of positive VM.

An unusual colonic mass in a phlebosclerosis patient

A 47-year-old man with idiopathic mesenteric phlebosclerosis presented to our hospital because of a 2-month history of diarrhea and edema of both lower limbs. Contrastenhanced abdominal computed tomography (CT) showed a 2-cm mass of mixed density in the ascending colon. On coloscopy, a solid, ulcerated, semi-pedunculated, lobulated protruding mass of 3.5×3.5×1.5 cm was observed and removed with hot snare polypectomy. Histologic examination demonstrated a hamartomatous polyp with normal epithelium and an inflammatory infiltrate with dilated, mucus-filled cystic glands in the lamina propria, indicating a juvenile polyp.

Safety of Cold Snare Polypectomy for Small Colorectal Polyps in Patients Receiving Antithrombotic Therapy

Background and AimsRecent guidelines do not specify the bleeding risk of cold polypectomy. We investigated delayed postpolypectomy bleeding (DPPB) after cold snare polypectomy (CSP) for colorectal polyps in patients receiving antithrombotic (AT) therapy. MethodsA total of 4770 patients who underwent endoscopic resection of colorectal polyps between April 2017 and December 2019 were included. Of them, we analyzed 3600 patients and 10,152 polyps with a size of < 10 mm, including 640 patients who took AT drugs. The patients were subdivided into 3 groups according to AT drug use: 1) continued use, 2) withdrawal, and 3) no use. We compared DPPB rates between hot snare polypectomy (HSP) and CSP in each group. ResultsThe DPPB rates in the CSP group were approximately one-tenth lower than those in the HSP group (per-patient analysis: 0 (0/2598) vs 0.9% (9/1002), per-polyp analysis: 0.04 (3/7928) vs 0.58% (13/2224)). The DPPB rates of HSP were significantly different among the continued use, withdrawal, and no use groups (per-polyp analysis: 2.08 (6/289), 0 (0/159), and 0.40% (7/1771), P = 0.0015). However, the DPPB rates of CSP did not differ among groups (per-polyp analysis: 0 (0/983), 0.17 (1/591), and 0.03% (2/6348), P = 0.2087). No DPPB was observed after CSP in patients with continued use of thienopyridine, aspirin, cilostazol, direct oral anticoagulants, or warfarin; except for 1 patient with direct oral anticoagulant withdrawal. ConclusionThe DPPB of CSP in patients taking an AT drug was low and similar to that in patients not taking drugs. CSP could be a safe procedure for colorectal polyps, even with continued use of AT drugs.

Comparison of postpolypectomy bleeding events between cold snare polypectomy and hot snare polypectomy for small colorectal lesions: a large-scale propensity score–matched analysis

Cold snare polypectomy (CSP), a safe procedure for removing colon polyps, has a low prevalence of postpolypectomy bleeding (PPB). Previous studies have failed to demonstrate differences in PPB rates between CSP and hot snare polypectomy (HSP), possibly because of their small sample sizes. This study analyzed PPB rates after CSP and HSP. This was a retrospective analysis of colorectal lesions (diameter<10mm) treated using endoscopic resection at our institution between January 2015 and December 2019. Resections were performed using CSP or HSP, depending on the endoscopist's preference. Endoscopic and histologic findings were recorded in the endoscopic database at our institution. Propensity score (PS) matching was performed to match patient age, lesion size, macroscopic features, location of the lesions, clipping after resection, and antithrombotic agent use. The CSP and HSP groups were compared to determine the adverse event (PPB) rates. The CSP and HSP groups included 12,928 and 2408 lesions (total of 5371 patients), respectively. Univariate analysis revealed that the overall prevalence of PPB after HSP was higher than that after CSP (odds ratio [OR], 5.39; 95% confidence interval [CI], 2.50-11.60). After PS matching (2135 lesions per group), the prevalence of PPB after HSP remained higher than that after CSP (OR, 6.0; 95% CI, 1.34-26.8). For colorectal lesions<10mm in diameter, the risk of PPB after CSP is significantly lower than that after HSP, after PS matching. CSP for lesions<10mm could be safely performed compared with HSP.

Correction: Efficacy and safety of cold versus hot snare polypectomy for small (5-9 mm) colorectal polyps: a multicenter randomized controlled trial.

Correction: Efficacy and safety of cold versus hot snare polypectomy for small (5-9 mm) colorectal polyps: a multicenter randomized controlled trial.

Prospective evaluation of the effectiveness of colonoscopic polyp resection

Background: Colon cancer incidence is on the rise and despite having undergone a colonoscopy to screen and remove all visible polyps as a preventive measure, nearly 1 in 110 patients will develop colon cancer within 3 years. The three main possible explanations for this are missing polyps, incompletely removed polyps, or rapidly growing tumors. Objective: To determine the proportion of colonic polyps ≤ 3 cm in size that show evidence of residual polyp tissue following colonoscopy and polypectomy. Methods: Patients who presented for colonoscopy at a community center were invited to participate in this study. Those who had confirmed adenoma were invited to repeat the procedure in 2 to 6 months with biopsies at the resection site to check for the presence of residual polyp tissue. Exclusion criteria included the absence of adenoma in the resected lesion, contraindication to polypectomy or follow-up colonoscopy, refusal to participate in follow-up examination, and other conditions increasing colon cancer risk. If polyps between 5 mm and 30 mm were found, the endoscopist resected them using the hot snare polypectomy technique or endoscopic mucosal resection (EMR). Results: Ninety-one patients completed the study protocol, with 105 lesions being studied. The second procedure was performed between 2 and 24 months. All analyzed lesions were adenoma, and three of them were associated with intramucosal adenocarcinoma. Others included 60 tubular lesions, 37 tubulovillous lesions, and 5 serrated lesions. Thirty-two lesions were flat and were removed by EMR; polypectomy was performed for 73 lesions. There was no residual tissue in the polypectomy group. The EMR group presented three cases of incomplete resection without adenocarcinomas. Conclusion: Our study showed that flat lesions might be an important cause of incomplete resection. In addition, we documented the complete resection of pedunculated lesions in all studied patients. This study provides more evidence to validate the empirical perception in the medical field that assumes the complete resection of pedunculated polyps. Therefore, we suggest that patients who undergo snare removal of pedunculated polyps should follow the regular protocol for colon cancer screening, with colonoscopy every 5 to 10 years. Meanwhile, the surveillance scheme should be reviewed for patients who undergo removal of flat lesions smaller than 30 mm.