Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods

Abstract

ObjectiveLarge (≥20 mm) sessile serrated lesions (L-SSL) are premalignant lesions that require endoscopic removal. Endoscopic mucosal resection (EMR) is the existing standard of care but carries some risk of adverse events including clinically significant post-EMR bleeding and deep mural injury (DMI). The respective risk-effectiveness ratio of piecemeal cold snare polypectomy (p-CSP) in L-SSL management is not fully known.DesignConsecutive patients referred for L-SSL management were treated by p-CSP from April 2016 to January 2020 or by conventional EMR in the preceding period between July 2008 and March 2016 at four Australian tertiary centres. Surveillance colonoscopies were conducted at 6 months (SC1) and 18 months (SC2). Outcomes on technical success, adverse events and recurrence were documented prospectively and then compared retrospectively between the subsequent time periods.ResultsA total of 562 L-SSL in 474 patients were evaluated of which 156 L-SSL in 121 patients were treated by p-CSP and 406 L-SSL in 353 patients by EMR. Technical success was equal in both periods (100.0% (n=156) vs 99.0% (n=402)). No adverse events occurred in p-CSP, whereas delayed bleeding and DMI were encountered in 5.1% (n=18) and 3.4% (n=12) of L-SSL treated by EMR, respectively. Recurrence rates following p-CSP were similar to EMR at 4.3% (n=4) versus 4.6% (n=14) and 2.0% (n=1) versus 1.2% (n=3) for surveillance colonoscopy (SC)1 and SC2, respectively.ConclusionsIn a historical comparison on the endoscopic management of L-SSL, p-CSP is technically equally efficacious to EMR but virtually eliminates the risk of delayed bleeding and perforation. p-CSP should therefore be considered as the new standard of care for L-SSL treatment.

AGA Clinical Practice Update on Strategies to Improve Quality of Screening and Surveillance Colonoscopy: Expert Review

“…Compared with hot snare polypectomy, cold snare polypectomy is equally efficacious, 78 substantially reduces the risk of delayed postpolypectomy bleeding, 78,79 avoids risk of thermal injury, and likely reduces the risk of polypectomy-associated bleeding and perforation. 80 Research on methods to improve polypectomy technique are limited. Recording colonoscopists' polypectomy technique with focused feedback improved polypectomy technique (as rated by experts), but this impact was demonstrated on diminutive and small polyps and it is unclear whether this actually improves completeness of polypectomy.…”

Cold versus hot polypectomy/endoscopic mucosal resection–A review of current evidence

“…However, comparative trials between the two approaches are still scarce, but there is a recent comparative trial showing similar technical success and recurrence rates between cold and hot EMR, while adverse events were significantly more frequent in the hot EMR group (5.1% vs. 0%). 36 …”

How to Manage the Large Nonpedunculated Colorectal Polyp

“…The primary indication for CSR is large sessile serrated polyps. In a multicenter analysis of 562 large sessile serrated polyps removed by either EMR or CSR, 4 no differences in technical success or recurrence were identified. However, differences in clinically significant postendoscopic resection bleeding (0% CSR vs 5.1% EMR) and deep mural injury (0%…”