Large colorectal polyps up to 15 mm in size can be safely and effectively removed with cold snare polypectomy (CSP), with a low incomplete resection rate, according to a single-center, observational study from China.
Multiple current guidelines recommend CSP for removing diminutive (≤ 5 mm) and small (6-9 mm) polyps, citing clinical data demonstrating that such an approach leads to high complete resection rates and a good safety profile.
However, the use of CSP for removing larger colorectal polyps (≥ 10 mm) remains controversial, with only limited safety and efficacy data.
Yuqi He, MD, from the department of gastroenterology at the Seventh Medical Center of Chinese PLA General Hospital in Beijing, and colleagues evaluated 440 neoplastic polyps removed by CSP from 261 patients (mean age, 56.6 years; 166 men).
Indications for colonoscopy were screening (53%), diagnostic (17%), polyp surveillance (24%), and other (6%).
Of the 440 polyps, 353 (80%) were small (5-9 mm) and 87 (20%) were large (10-15 mm); 379 (86%) were adenomas, 59 (13%) were sessile serrated lesions (SSL), and 2 (<1%) were high-grade dysplasia.
For all polyps (5-15 mm), the incomplete resection rate (primary outcome) was 2.27%. Incomplete resection was more common for large polyps (3.45%) compared with small polyps (1.98%), but the difference was not statistically significant (P = .411).
In univariate analysis, factors associated with incomplete resection were SSL, piecemeal resection, and prolonged resection time.
In multivariate regression analysis, independent risk factors for incomplete resection were SSL (odds ratio [OR] 6.45; 95% CI, 1.48 – 28.03; P = .013) and prolonged resection time (OR, 7.39; 95% CI, 1.48 – 36.96; P = .015).
Immediate bleeding was more common with resection of large polyps (6.9% vs 1.42%, P = .003).
There were no recurrences on follow-up colonoscopy in 37 cases with large polyps, further supporting the efficacy of CSP for this size group, the researchers say.
Their study was published online November 16 in Clinical Gastroenterology and Hepatology.
Important Study, Lingering Questions, Experts Say
Reached for comment, Rajesh N. Keswani, MD, of Northwestern University Feinberg School of Medicine in Chicago, Illinois, said, “It is standard practice to remove polyps <10 mm using cold techniques. We generally advocate for use of a cold snare for polyps 3-9 mm in size; either large cold forceps or a cold snare can be used for polyps 1-2 mm in size,” a recommendation also conveyed in the American Gastroenterological Association’s recent clinical practice update.
“It is still unclear whether cold polypectomy techniques are appropriate for larger lesions,” Keswani, who wasn’t involved in the study, told Medscape Medical News.
“For larger polyps that require piecemeal technique (generally > 2 cm), there are multiple small studies showing that resection using cold snare piecemeal technique may be safe and effective, at minimum for serrated lesions. There has been enough interest in this approach that is being formally studied in a large multicenter trial,” he noted.
“Based on the safety and efficacy data thus far for cold snare polypectomy in larger serrated lesions, it would be difficult to think that it would not be a safe choice for serrated lesions 10-20 mm,” Keswani commented.
However, the data remain “unclear for adenomatous lesions 10-20 mm in size. Unfortunately, in this study only 87 polyps 10-15 mm [in size] were removed, and a proportion were serrated and a proportion were adenomas,” he told Medscape Medical News.
“Thus, I don’t think this study is able to answer one of our key remaining polypectomy questions, which is whether cold snare techniques are the optimal approach for adenomas >10 mm in size,” said Keswani.
Also weighing in was Emre Gorgun, MD, with the Cleveland Clinic in Cleveland, Ohio, who said it’s “an important study in the sense it raises awareness to the role of cold snaring techniques, especially since it is less expensive, quicker, and safe.”
“Late complications related to possibly using energy might be also eliminated. However, results for expanding the practice to larger polyps up to 15 mm should be taken cautiously into consideration,” Gorgun told Medscape Medical News.
“The threat of bleeding in high-risk patients, for example with a history of anticoagulation use, were not reported. Other patient-related factors can increase these risks as well. Additionally, the long-term follow-up is not reported,” commented Gorgun, who was not associated with the research.
“This study triggers the idea of using cold snaring in larger polyps; however, the results should be further reproduced and verified for long-term consequences and safety,” he concluded.
The authors have disclosed no relevant financial relationships. Keswani is a c onsultant for Boston Scientific and Neptune Medical and receives research support from Virgo. Gorgun is a consultant for Boston Scientific. Support for the study was provided b y grants from Project of Army Special Care and Beijing Municipal Science and Technology Commission.
Clin Gastroenterol Hepatol. Published online November 16, 2021. Abstract
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