Q&A: Clinicians ‘should routinely offer’ cold snare polypectomy for small polyps
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Cold snare polypectomy for colorectal polyps smaller than 1 cm significantly reduced the risk for delayed bleeding and improved procedural efficiency compared with hot snare polypectomy, according to data in Annals of Internal Medicine.
“Along with the popularity of colorectal cancer screening, there is an increasing number of colonoscopies being performed in clinical practice — 16 million in the U.S. and 400,000 in Taiwan annually,” Han-Mo Chiu, MD, PhD, clinical professor of internal medicine at National Taiwan University, told Healio. “As the majority — more than 80% — of the polyps detected at colonoscopy are smaller than 1 cm, a safe and efficient way of removing those lesions is indispensable.”
In a multicenter, randomized controlled study, Chiu and colleagues enrolled 4,270 participants, aged 40 years or older, with polyps 4 mm to 10 mm in size. Participants underwent cold snare polypectomy (n = 2,137) or hot snare polypectomy (n = 2,133).
According to results, delayed bleeding occurred in eight patients (0.4% ) in the cold snare group and 31 patients (1.5%) in the hot snare group (risk difference = –1.1%; 95% CI, –1.7 to –0.5), with severe delayed bleeding in 0.05% vs. 0.4%, respectively (risk difference = –0.3%; 95% CI, –0.6 to –0.05).
Further, patients in the cold snare group experienced shorter mean polypectomy time (119 seconds vs. 162.9 seconds) and fewer emergency service visits (0.2% vs. 0.6%). Successful tissue retrieval, en bloc resection and complete histologic resection did not differ between groups.
Chiu spoke with Healio about how these results may inform patient care and what additional research is needed.
Healio: Why did your team conduct this investigation?
Chiu: Though cold snare polypectomy has been implemented in clinical practice for a decade for removing small polyps and is considered effective in reducing the risk for post-polypectomy bleeding, a large-scale randomized trial with sufficient power in the general population using bleeding as the primary endpoint was still lacking. We conducted this multicenter, randomized controlled trial to fill this knowledge and evidence gap.
Healio: What were the key takeaways?
Chiu: Cold snare polypectomy is a speedy technique that could significantly improve the efficiency of the procedure and reduce the risk for delayed bleeding. It should be considered the standard of care for resecting colorectal polyps smaller than 1 cm.
It is worthwhile to mention that all the bleeding episodes in the cold snare group occurred within 48 hours, whereas bleeding in the hot snare group may occur on the ninth day after the procedure. Such a finding has great impact on the scheduling of colonoscopy and improves the quality of life of the patients after polypectomy. Both clinicians and patients will benefit from such a paradigm shift in colonoscopy practice.
Healio: What additional research is needed?
Chiu: Along with the increasing aging population in many developed countries, people using antithrombotic agents — either single agent or combination use — is increasing, which increases the risk for delayed post-polypectomy bleeding.
Those agents act differently in terms of mechanism and carry different risks for bleeding, but routinely stopping these agents may increase the risk for cardiovascular or cerebrovascular events. Exploration of safe approaches balancing procedural and conditional risk is warranted.
Though we have demonstrated the comparable efficacy of cold snare polypectomy in the completeness of removing polyps measured by en bloc resection rate and complete histological eradication rate, it is necessary to explore the risk of residual neoplasm — or local recurrence — after such a procedure and compare with hot polypectomy. A follow-up study of the patients enrolled in this randomized trial is ongoing.
Healio: How might these results inform patient care?
Chiu: Given that cold snare polypectomy is becoming the standard of care in managing subcentimetric polyps, the clinician should routinely offer this practice to the patient.
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